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TURKISH JOURNAL of TRAUMA & EMERGENCY SURGERY Ulusal Travma ve Acil Cerrahi Dergisi

ISSN 1306 - 696X

TURKISH JOURNAL of TRAUMA & EMERGENCY SURGERY Ulusal Travma ve Acil Cerrahi Dergisi

Tanrıkulu CŞ, et al. p. 317

Volume 25 | Number 4 | July 2019

Volume 25 | Number 4 | July 2019

www.tjtes.org


ISSN 1306 - 696X

TURKISH JOURNAL of TRAUMA & EMERGENCY SURGERY Ulusal Travma ve Acil Cerrahi Dergisi

Volume 25 | Number 4 | July 2019

www.tjtes.org


TURKISH JOURNAL of TRAUMA & EMERGENCY SURGERY Ulusal Travma ve Acil Cerrahi Dergisi Editor-in-Chief Recep Güloğlu Editors Kaya Sarıbeyoğlu M. Mahir Özmen Hakan Yanar Former Editors Ömer Türel, Cemalettin Ertekin, Korhan Taviloğlu Section Editors Anaesthesiology & ICU Güniz Meyancı Köksal, Mert Şentürk Cardiac Surgery Münacettin Ceviz, Murat Güvener Neurosurgery Ahmet Deniz Belen, Mehmet Yaşar Kaynar Ophtalmology Cem Mocan, Halil Ateş Ortopedics and Traumatology Mahmut Nedim Doral, Mehmet Can Ünlü Plastic and Reconstructive Surgery Ufuk Emekli, Figen Özgür Pediatric Surgery Aydın Yagmurlu, Ebru Yeşildağ Thoracic Surgery Alper Toker, Akif Turna Urology Ali Atan, Öner Şanlı Vascular Surgery Cüneyt Köksoy, Mehmet Kurtoğlu

www.tjtes.org


THE TURKISH ASSOCIATION OF TRAUMA AND EMERGENCY SURGERY ULUSAL TRAVMA VE ACİL CERRAHİ DERNEĞİ President (Başkan) Vice President (2. Başkan) Secretary General (Genel Sekreter) Treasurer (Sayman) Members (Yönetim Kurulu Üyeleri)

Orhan Alimoğlu Mehmet Eryılmaz Ali Fuat Kaan Gök Gökhan Akbulut Osman Şimşek Münevver Moran Adnan Özpek

CORRESPONDENCE İLETİŞİM Ulusal Travma ve Acil Cerrahi Derneği Şehremini Mah., Köprülü Mehmet Paşa Sok. Dadaşoğlu Apt., No: 25/1, 34104 Şehremini, İstanbul, Turkey

Tel: +90 212 - 588 62 46 Fax (Faks): +90 212 - 586 18 04 e-mail (e-posta): travma@travma.org.tr Web: www.travma.org.tr

ISSUED BY THE TURKISH ASSOCIATION OF TRAUMA AND EMERGENCY SURGERY ULUSAL TRAVMA VE ACİL CERRAHİ DERNEĞİ YAYIN ORGANI Owner (Ulusal Travma ve Acil Cerrahi Derneği adına Sahibi) Editorial Director (Yazı İşleri Müdürü) Managing Editor (Yayın Koordinatörü) Publication Secretary (Yayın Sekreteri) Emblem (Amblem) Correspondence address (Yazışma adresi) Tel Fax (Faks)

Kaya Sarıbeyoğlu Kaya Sarıbeyoğlu M. Mahir Özmen Kerem Ayar Metin Ertem Ulusal Travma ve Acil Cerrahi Dergisi Sekreterliği Şehremini Mah., Köprülü Mehmet Paşa Sok., Dadaşoğlu Apt., No: 25/1, 34104 Şehremini, İstanbul +90 212 - 531 12 46 - 588 62 46 +90 212 - 586 18 04

p-ISSN 1306-696x • e-ISSN 1307-7945 • Included in Index Medicus, Medline; EMBASE, Excerpta Medica; Science Citation Index-Expanded (SCI-E), Index Copernicus, DOAJ, EBSCO, and Turkish Medical Index (Index Medicus, Medline; EMBASE, Excerpta Medica; Science Citation Index-Expanded (SCI-E), Index Copernicus, DOAJ, EBSCO ve TÜBİTAK ULAKBİM Türk Tıp Dizini’nde yer almaktadır.) Publisher (Yayımcı): KARE Yayıncılık (KARE Publishing) • www.kareyayincilik.com • Design (Tasarım): Ali Cangül • Graphics (Grafikler): Edibe Çomaktekin • Linguistic Editor (İngilizce Editörü): Suzan Atwood • Redaction (Redaksiyon): Erman Aytaç • Online Manuscript & Web Management (Online Dergi & Web): LookUs • Press (Baskı): Yıldırım Matbaacılık • Press date (Basım tarihi): July (Temmuz) 2019 • This publication is printed on paper that meets the international standard ISO 9706: 1994 (Bu dergide kullanılan kağıt ISO 9706: 1994 standardına uygundur.)

KARE P U B L I S H I N G

www.tjtes.org


INFORMATION FOR THE AUTHORS The Turkish Journal of Trauma and Emergency Surgery (TJTES) is an official publication of the Turkish Association of Trauma and Emergency Surgery. It is a peer-reviewed periodical that considers for publication clinical and experimental studies, case reports, technical contributions, and letters to the editor. Six issues are published annually.

tion, called “Upload Your Files”.

As from 2001, the journal is indexed in Index Medicus and Medline, as from 2005 in Excerpta Medica and EMBASE, as from 2007 in Science Citation Index Expanded (SCI-E) and Journal Citation Reports / Science Edition, and as from 2014 in EBSCOhost. Our impact factor in SCI-E indexed journals is 0.643 (JCR 2018). It is cited as ‘Ulus Travma Acil Cerrahi Derg’ in PubMed.

Figures, illustrations and tables: All figures and tables should be numbered in the order of appearance in the text. The desired position of figures and tables should be indicated in the text. Legends should be included in the relevant part of the main text and those for photomicrographs and slide preparations should indicate the magnification and the stain used. Color pictures and figures will be published if they are definitely required and with the understanding that the authors are prepared to bear the costs. Line drawings should be professionally prepared. For recognizable photographs, signed releases of the patient or of his/her legal representatives should be enclosed; otherwise, patient names or eyes must be blocked out to prevent identification.

Submission of a manuscript by electronic means implies: that the work has not been published before (except in the form of an abstract or as part of a published lecture, review, or thesis); that it is not under consideration for publication elsewhere; and that its publication in the Turkish Journal of Trauma and Emergency Surgery is approved by all co-authors. The author(s) transfer(s) the copyright to the Turkish Association of Trauma and Emergency Surgery to be effective if and when the manuscript is accepted for publication. The author(s) guarantee(s) that the manuscript will not be published elsewhere in any other language without the consent of the Association. If the manuscript has been presented at a meeting, this should be stated together with the name of the meeting, date, and the place. Manuscripts must be submitted in English. All submissions are initially reviewed by the editor, and then are sent to reviewers. All manuscripts are subject to editing and, if necessary, will be returned to the authors for answered responses to outstanding questions or for addition of any missing information to be added. For accuracy and clarity, a detailed manuscript editing is undertaken for all manuscripts accepted for publication. Final galley proofs are sent to the authors for approval. Unless specifically indicated otherwise at the time of submission, rejected manuscripts will not be returned to the authors, including accompanying materials. TJTES is indexed in Science Citation Index-Expanded (SCI-E), Index Medicus, Medline, EMBASE, Excerpta Medica, and the Turkish Medical Index of TUBITAK-ULAKBIM. Priority of publications is given to original studies; therefore, selection criteria are more refined for reviews and case reports. Open Access Policy: Full text access is free. There is no charge for publication or downloading the full text of printed material. Manuscript submission: TJTES accepts only on-line submission via the official web site (please click, www.travma.org.tr/en) and refuses printed manuscript submissions by mail. All submissions are made by the on-line submission system called Journal Agent, by clicking the icon “Online manuscript submission” at the above mentioned web site homepage. The system includes directions at each step but for further information you may visit the web site (http://www.travma.org/en/ journal/). Manuscript preparation: Manuscripts should have double-line spacing, leaving sufficient margin on both sides. The font size (12 points) and style (Times New Roman) of the main text should be uniformly taken into account. All pages of the main text should be numbered consecutively. Cover letter, manuscript title, author names and institutions and correspondence address, abstract in Turkish (for Turkish authors only), and title and abstract in English are uploaded to the Journal Agent system in the relevant steps. The main text includes Introduction, Materials and Methods, Results, Discussion, Acknowledgments, References, Tables and Figure Legends. The cover letter must contain a brief statement that the manuscript has been read and approved by all authors, that it has not been submitted to, or is not under consideration for publication in, another journal. It should contain the names and signatures of all authors. The cover letter is uploaded at the 10th step of the “Submit New Manuscript” sec-

Abstract: The abstract should be structured and serve as an informative guide for the methods and results sections of the study. It must be prepared with the following subtitles: Background, Methods, Results and Conclusions. Abstracts should not exceed 200 words.

References: All references should be numbered in the order of mention in the text. All reference figures in the text should be given in brackets without changing the font size. References should only include articles that have been published or accepted for publication. Reference format should conform to the “Uniform requirements for manuscripts submitted to biomedical journals” (http://www.icmje.org) and its updated versions (February 2006). Journal titles should be abbreviated according to Index Medicus. Journal references should provide inclusive page numbers. All authors, if six or fewer, should be listed; otherwise the first six should be listed, followed by “et al.” should be written. The style and punctuation of the references should follow the formats below: Journal article: Velmahos GC, Kamel E, Chan LS, Hanpeter D, Asensio JA, Murray JA, et al. Complex repair for the management of duodenal injuries. Am Surg 1999;65:972-5. Chapter in book: Jurkovich GJ. Duodenum and pancreas. In: Mattox KL, Feliciano DV, Moore EE, editors. Trauma. 4th ed. New York: McGraw-Hill; 2000. p. 735-62. Our journal has succeeded in being included in several indexes, in this context, we have included a search engine in our web site (www. travma.org.tr) so that you can access full-text articles of the previous issues and cite the published articles in your studies. Review articles: Only reviews written by distinguished authors based on the editor’s invitation will be considered and evaluated. Review articles must include the title, summary, text, and references sections. Any accompanying tables, graphics, and figures should be prepared as mentioned above. Case reports: A limited number of case reports are published in each issue of the journal. The presented case(s) should be educative and of interest to the readers, and should reflect an exclusive rarity. Case reports should contain the title, summary, and the case, discussion, and references sections. These reports may consist of maximum five authors. Letters to the Editor: “Letters to the Editor” are only published electronically and they do not appear in the printed version of TJTES and PUBMED. The editors do not issue an acceptance document as an original article for the ‘’letters to the editor. The letters should not exceed 500 words. The letter must clearly list the title, authors, publication date, issue number, and inclusive page numbers of the publication for which opinions are released. Informed consent - Ethics: Manuscripts reporting the results of experimental studies on human subjects must include a statement that informed consent was obtained after the nature of the procedure(s) had been fully explained. Manuscripts describing investigations in animals must clearly indicate the steps taken to eliminate pain and suffering. Authors are advised to comply with internationally accepted guidelines, stating such compliance in their manuscripts and to include the approval by the local institutional human research committee.


YAZARLARA BİLGİ Ulusal Travma ve Acil Cerrahi Dergisi, Ulusal Travma ve Acil Cerrahi Derneği’nin yayın organıdır. Travma ve acil cerrahi hastalıklar konularında bilimsel birikime katkısı olan klinik ve deneysel çalışmaları, editöryel yazıları, klinik olgu sunumlarını ve bu konulardaki teknik katkılar ile son gelişmeleri yayınlar. Dergi iki ayda bir yayınlanır. Ulusal Travma ve Acil Cerrahi Dergisi TÜBİTAK TR Dizinde taranmaktadır, ayrıca uluslararası indekslerde, 2001 yılından itibaren Index Medicus, PubMed’de, 2005 yılından itibaren EMBASE’de, 2007 yılından itibaren Web of Science, Science Citation Index-Expanded’de (SCI-E), 2014 yılından itibaren de EBSCOhost indeksinde dizinlenmektedir. 2018 Journal Citation Report IF puanımız 0.643 olmuştur. Dergide araştırma yazılarına öncelik verilmekte, bu nedenle derleme veya olgu sunumu türündeki yazılarda seçim ölçütleri daha dar tutulmaktadır. PUBMED’de dergi “Ulus Travma Acil Cerrahi Derg” kısaltması ile yer almaktadır. Dergiye yazı teslimi, çalışmanın daha önce yayınlanmadığı (özet ya da bir sunu, inceleme, ya da tezin bir parçası şeklinde yayınlanması dışında), başka bir yerde yayınlanmasının düşünülmediği ve Ulusal Travma ve Acil Cerrahi Dergisi’nde yayınlanmasının tüm yazarlar tarafından uygun bulunduğu anlamına gelmektedir. Yazar(lar), çalışmanın yayınlanmasının kabulünden başlayarak, yazıya ait her hakkı Ulusal Travma ve Acil Cerrahi Derneği’ne devretmektedir(ler). Yazar(lar), izin almaksızın çalışmayı başka bir dilde ya da yerde yayınlamayacaklarını kabul eder(ler). Gönderilen yazı daha önce herhangi bir toplantıda sunulmuş ise, toplantı adı, tarihi ve düzenlendiği şehir belirtilmelidir. Dergide İngilizce yazılmış makaleler yayınlanır. Tüm yazılar önce editör tarafından ön değerlendirmeye alınır; daha sonra incelenmesi için danışma kurulu üyelerine gönderilir. Tüm yazılarda editöryel değerlendirme ve düzeltmeye başvurulur; gerektiğinde, yazarlardan bazı soruları yanıtlanması ve eksikleri tamamlanması istenebilir. Dergide yayınlanmasına karar verilen yazılar “manuscript editing” sürecine alınır; bu aşamada tüm bilgilerin doğruluğu için ayrıntılı kontrol ve denetimden geçirilir; yayın öncesi şekline getirilerek yazarların kontrolüne ve onayına sunulur. Editörün, kabul edilmeyen yazıların bütününü ya da bir bölümünü (tablo, resim, vs.) iade etme zorunluluğu yoktur. Açık Erişim İlkesi: Tam metinlere erişim ücretsizdir. Yayınlanan basılı materyali tam metni indirmek için herhangi bir ücret alınmaz. Yazıların hazırlanması: Tüm yazılı metinler 12 punto büyüklükte “Times New Roman” yazı karakterinde iki satır aralıklı olarak yazılmalıdır. Sayfada her iki tarafta uygun miktarda boşluk bırakılmalı ve ana metindeki sayfalar numaralandırılmalıdır. Journal Agent sisteminde, başvuru mektubu, başlık, yazarlar ve kurumları, iletişim adresi, Türkçe özet ve yazının İngilizce başlığı ve özeti ilgili aşamalarda yüklenecektir. İngilizce yazılan çalışmalara da Türkçe özet eklenmesi gerekmektedir. Yazının ana metnindeyse şu sıra kullanılacaktır: Giriş, Gereç ve Yöntem, Bulgular, Tartışma, Teşekkür, Kaynaklar, Tablolar ve Şekiller. Başvuru mektubu: Bu mektupta yazının tüm yazarlar tarafından okunduğu, onaylandığı ve orijinal bir çalışma ürünü olduğu ifade edilmeli ve yazar isimlerinin yanında imzaları bulunmalıdır. Başvuru mektubu ayrı bir dosya olarak, Journal Agent sisteminin “Yeni Makale Gönder” bölümünde, 10. aşamada yer alan dosya yükleme aşamasında yollanmalıdır. Başlık sayfası: Yazının başlığı, yazarların adı, soyadı ve ünvanları, çalışmanın yapıldığı kurumun adı ve şehri, eğer varsa çalışmayı destekleyen fon ve kuruluşların açık adları bu sayfada yer almalıdır. Bu sayfaya ayrıca “yazışmadan sorumlu” yazarın isim, açık adres, telefon, faks, mobil telefon ve e-posta bilgileri eklenmelidir. Özet: Çalışmanın gereç ve yöntemini ve bulgularını tanıtıcı olmalıdır. Türkçe özet, Amaç, Gereç ve Yöntem, Bulgular, Sonuç ve Anahtar Sözcükler başlıklarını; İngilizce özet Background, Methods, Results, Conclusion ve Key words başlıklarını içermelidir. İngilizce olarak hazırlanan çalışmalarda da Türkçe özet yer almalıdır. Özetler başlıklar hariç 190210 sözcük olmalıdır. Tablo, şekil, grafik ve resimler: Şekillere ait numara ve açıklayıcı bilgiler ana metinde ilgili bölüme yazılmalıdır. Mikroskobik şekillerde resmi açıklayıcı bilgilere ek olarak, büyütme oranı ve kullanılan boyama tekniği de belirtilmelidir. Yazarlara ait olmayan, başka kaynaklarca daha önce yayınlanmış tüm resim, şekil ve tablolar için yayın hakkına sahip kişilerden izin alınmalı ve izin belgesi dergi editörlüğüne ayrıca açıklamasıyla

birlikte gönderilmelidir. Hastaların görüntülendiği fotoğraflara, hastanın ve/veya velisinin imzaladığı bir izin belgesi eşlik etmeli veya fotoğrafta hastanın yüzü tanınmayacak şekilde kapatılmış olmalıdır. Renkli resim ve şekillerin basımı için karar hakemler ve editöre aittir. Yazarlar renkli baskının hazırlık aşamasındaki tutarını ödemeyi kabul etmelidirler. Kaynaklar: Metin içindeki kullanım sırasına göre düzenlenmelidir. Makale içinde geçen kaynak numaraları köşeli parantezle ve küçültülmeden belirtilmelidir. Kaynak listesinde yalnızca yayınlanmış ya da yayınlanması kabul edilmiş çalışmalar yer almalıdır. Kaynak bildirme “Uniform Requirements for Manuscripts Submitted to Biomedical Journals” (http:// www.icmje.org) adlı kılavuzun en son güncellenmiş şekline (Şubat 2006) uymalıdır. Dergi adları Index Medicus’a uygun şekilde kısaltılmalıdır. Altı ya da daha az sayıda olduğunda tüm yazar adları verilmeli, daha çok yazar durumunda altıncı yazarın arkasından “et al.” ya da “ve ark.” eklenmelidir. Kaynakların dizilme şekli ve noktalamalar aşağıdaki örneklere uygun olmalıdır: Dergi metni için örnek: Velmahos GC, Kamel E, Chan LS, Hanpeter D, Asensio JA, Murray JA, et al. Complex repair for the management of duodenal injuries. Am Surg 1999;65:972-5. Kitaptan bölüm için örnek: Jurkovich GJ. Duodenum and pancreas. In: Mattox KL, Feliciano DV, Moore EE, editors. Trauma. 4th ed. New York: McGraw-Hill; 2000. p. 735-62. Sizlerin çalışmalarınızda kaynak olarak yararlanabilmeniz için www.travma.org.tr adresli web sayfamızda eski yayınlara tam metin olarak ulaşabileceğiniz bir arama motoru vardır. Derleme yazıları: Bu tür makaleler editörler kurulu tarafından gerek olduğunda, konu hakkında birikimi olan ve bu birikimi literatüre de yansımış kişilerden talep edilecek ve dergi yazım kurallarına uygunluğu saptandıktan sonra değerlendirmeye alınacaktır. Derleme makaleleri; başlık, Türkçe özet, İngilizce başlık ve özet, alt başlıklarla bölümlendirilmiş metin ile kaynakları içermelidir. Tablo, şekil, grafik veya resim varsa yukarıda belirtildiği şekilde gönderilmelidir. Olgu sunumları: Derginin her sayısında sınırlı sayıda olgu sunumuna yer verilmektedir. Olgu bildirilerinin kabulünde, az görülürlük, eğitici olma, ilginç olma önemli ölçüt değerlerdir. Ayrıca bu tür yazıların olabildiğince kısa hazırlanması gerekir. Olgu sunumları başlık, Türkçe özet, İngilizce başlık ve özet, olgu sunumu, tartışma ve kaynaklar bölümlerinden oluşmalıdır. Bu tür çalışmalarda en fazla 5 yazara yer verilmesine özen gösterilmelidir. Editöre mektuplar: Editöre mektuplar basılı dergide ve PUBMED’de yer almamakta, ancak derginin web sitesinde yayınlanmaktadır. Bu mektuplar için dergi yönetimi tarafından yayın belgesi verilmemektedir. Daha önce basılmış yazılarla ilgili görüş, katkı, eleştiriler ya da farklı bir konu üzerindeki deneyim ve düşünceler için editöre mektup yazılabilir. Bu tür yazılar 500 sözcüğü geçmemeli ve tıbbi etik kurallara uygun olarak kaleme alınmış olmalıdır. Mektup basılmış bir yazı hakkında ise, söz konusu yayına ait yıl, sayı, sayfa numaraları, yazı başlığı ve yazarların adları belirtilmelidir. Mektup bir konuda deneyim, düşünce hakkında ise verilen bilgiler doğrultusunda dergi kurallarına uyumlu olarak kaynaklar da belirtilmelidir. Bilgilendirerek onay alma - Etik: Deneysel çalışmaların sonuçlarını bildiren yazılarda, çalışmanın yapıldığı gönüllü ya da hastalara uygulanacak prosedür(lerin) özelliği tümüyle anlatıldıktan sonra, onaylarının alındığını gösterir bir cümle bulunmalıdır. Yazarlar, bu tür bir çalışma söz konusu olduğunda, uluslararası alanda kabul edilen kılavuzlara ve T.C. Sağlık Bakanlığı tarafından getirilen yönetmelik ve yazılarda belirtilen hükümlere uyulduğunu belirtmeli ve kurumdan aldıkları Etik Komitesi onayını göndermelidir. Hayvanlar üzerinde yapılan çalışmalarda ağrı, acı ve rahatsızlık verilmemesi için neler yapıldığı açık bir şekilde belirtilmelidir. Yazı gönderme - Yazıların gönderilmesi: Ulusal Travma ve Acil Cerrahi Dergisi yalnızca www.travma.org.tr adresindeki internet sitesinden on-line olarak gönderilen yazıları kabul etmekte, posta yoluyla yollanan yazıları değerlendirmeye almamaktadır. Tüm yazılar ilgili adresteki “Online Makale Gönderme” ikonuna tıklandığında ulaşılan Journal Agent sisteminden yollanmaktadır. Sistem her aşamada kullanıcıyı bilgilendiren özelliktedir.


TURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY ULUSAL TRAVMA VE ACİL CERRAHİ DERGİSİ Vol. - Cilt 25

Number - Sayı 4 July - Temmuz 2019

Contents - İçindekiler

Deneysel Çalışma - Experimental Experimental Studies - DeneyselStudy Çalışma 317-323 The protective and anti-inflammatory effect of methylene blue in corrosive esophageal burns: An experimental study Korozif özefagus yanıklarında metilen mavisinin koruyucu ve anti-enflamatuvar etkisi: Deneysel çalışma Şen Tanrıkulu C, Tanrıkulu Y, Kılınç F, Bahadır B, Can M, Köktürk F, Kefeli A 324-330 Comparison of the effects of two different marine-derived omega-3 fatty acid sources, krill oil, and fish oil, on the healing of primary colonic anastomoses after colectomy applied Wistar albino rat model Deniz kaynaklı, iki farklı omega-3 yağ asidi kaynağının, krill yağı ve balık yağı, primer kolon anastomozlarının iyileşmesi üzerindeki etkilerinin kolektomi uygulanan Wistar albino sıçan modeli ile karşılaştırılması Ferhatoğlu MF, Kıvılcım T, Vural G, Kartal A, Filiz Aİ, Kebudi A 331-337 Relationship between arterial oxygen tension and mortality of patients in intensive care unit on mechanical ventilation support Yoğun bakım ünitesinde mekanik ventilatör desteği ile takip edilen hastalarda arteriyel oksijen basıncı ile mortalite arasındaki ilişki Kaydu A, Orhun G, Çakar N 338-342 Comparison of Ankaferd Blood Stopper and silver sulfadiazine use in burn wounds: An experimental study Yanık yarası tedavisinde Ankaferd Blood Stoper ile gümüş sülfadiazinin karşılaştırılması: Deneysel çalışma Ay S, Ünlü Y 343-349 Assessing the therapeutic effect of resveratrol in heart failure following blunt chest trauma and the potential role of endocan as a biomarker of inflammation using rats Sıçanlarda künt göğüs travma sonrası oluşan kalp hasarı üzerine resveratrolün tedavi edici etkisinin ve endokanın enflamasyonda bir biyobelirteç olarak potansiyel rolünün değerlendirilmesi Torun AÇ, Tütüncü Ş

Original Articles - Orijinal Çalışma 350-354 Role of angiotensin-converting enzyme as prognostic marker in thoracic trauma: A prospective observational study Toraks travmasında bir prognostik belirteç olarak anjiyotensin dönüştürücü enzimin rolü: Bir ileriye yönelik gözlemsel çalışma Kumar S, Pal AK, Suman AK, Kumar S, Yadav GC, Ahmad MK 355-360 Role of ultrasonography in determining the cricothyroid membrane localization in the predicted difficult airway Öngörülen zor havayolunda krikotiroit membran lokalizasyonunun belirlenmesinde ultrasonografinin rolü Altun D, Ali A, Koltka K, Büget M, Çelik M, Doruk C, Çamcı AE 361-368 Mapping and prediction of organ procurement in cases resulting in mortality due to traumatic injuries: A matched cohort analysis Travmatik yaralanmalara bağlı mortaliteyle sonuçlanan durumlarda organ alımlarının haritalanması ve tahmini: Eşleşmiş kohort analizi Albuz Ö Ulus Travma Acil Cerrahi Derg, July 2019, Vol. 25, No. 4

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TURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY ULUSAL TRAVMA VE ACİL CERRAHİ DERGİSİ Vol. - Cilt 25

Number - Sayı 4 July - Temmuz 2019

Contents - İçindekiler 369-377 Comparison of ultrasound and physical examination with computerized tomography in patients with blunt abdominal trauma Künt karın travmalı hastalarda ultrasonografi ve fizik muayenenin bilgisayarlı tomografi ile karşılaştırılması Hekimoğlu A, Ergun O, Özkan S, Arslan ED, Hekimoğlu B 378-382 How necessary is the computerized brain tomography in minor head trauma? Minör kafa travmasında bilgisayarlı beyin tomografisi ne kadar gerekli? Yıldızhan S, Boyacı MG, Özdinç Ş 383-388 Retrospective analysis of decompressive craniectomy performed in pediatric patients with subdural hematoma Akut subdural hematom nedeni ile pediyatrik yaş grubunda dekompresif kraniyektomi uygulanan hastaların geriye dönük analizi Taşkapılıoğlu MÖ, Özmarasalı Aİ, Ocakoğlu G 389-395 Effect of temporary vascular shunting as a previous intervention on lower extremity arterial injury: Single center experiences in the Syrian Civil War Alt ekstremite arteriyel yaralanmalarında ilk müdahalede geçici vasküler şant uygulamasının etkileri: Suriye iç savaşında tek merkez deneyimleri Hasde Aİ, Baran Ç, Gümüş F, Kış M, Özçınar E, Çakıcı M, Yazıcıoğlu L, Kaya B 396-402 Effectiveness of conservative approach in right colon diverticulitis Sağ kolon divertikülitinde konservatif yaklaşımın etkinliği Destek S, Gül VO 403-409 Effects of psychological factors on the clinical outcomes of fifth metacarpal neck fractures and their relation to injury etiology Psikolojik faktörlerin beşinci metakarpal boyun kırıklarının klinik sonuçları üzerine etkileri ve yaralanma etiyolojisi ile ilişkisi Adıyeke L, Aydoğmuş S, Sabuncuoğlu M, Bilgin E, Duymuş TM 410-416 Examining implant superiority in the treatment of simple pertrochanteric fractures of the proximal femur in elderly patients Yaşlı hastalarda proksimal femur basit pertrokanterik kırıkların tedavisinde hangi implant üstündür? Talmaç MA, Görgel MA, Armağan R, Sönmez MM, Özdemir HM

Case Reports - Olgu Sunumu 417-423 Steel rod impalement injuries involving the spine: A case report and literature review Omurgaya saplanan çelik çubuk: Olgu sunumu ve literatür taraması Sarıca C, Yücetaş ŞC, Üçler N, Ballı S, Turgut K, Topçu Sarıca L, Kılınç S 424-426 Spontaneous transvaginal small bowel evisceration following hysterectomy: a case report Histerektomi sonrası geç dönem transvajinal ince bağırsak evisserasyonu: Olgu sunumu Yanar F, Öner G, Özçınar B, Gök AFK, Ertekin C

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EXPERIMENTAL STUDY

The protective and anti-inflammatory effect of methylene blue in corrosive esophageal burns: An experimental study Ceren Şen Tanrıkulu, M.D.,1 Yusuf Tanrıkulu, M.D.,2 Fahriye Kılınç, M.D.,3 Murat Can, M.D.,5 Fürüzan Köktürk, M.D.,6 Ayşe Kefeli, M.D.7

Burak Bahadır, M.D.,4

1

Department of Emergency Medicine, Health Sciences University, Konya Training and Research Hospital, Konya-Turkey

2

Department of General Surgery, KTO Karatay University Faculty of Medicine, Konya-Turkey

3

Department of Pathology, Necmettin Erbakan University Faculty of Medicine, Konya-Turkey

4

Department of Pathology, Bülent Ecevit University Faculty of Medicine, Zonguldak-Turkey

5

Department of Biochemistry, Bülent Ecevit University Faculty of Medicine, Zonguldak-Turkey

6

Department of Biostatistics, Bülent Ecevit University Faculty of Medicine, Zonguldak-Turkey

7

Department of Gastroenterology, Gaziosmanpasa University Faculty of Medicine, Tokat-Turkey

ABSTRACT BACKGROUND: In developing countries, esophageal burns are quite common. They are caused by the ingestion of corrosive substances that may lead to esophageal perforation in the short-term and stricture formation in the long-term. Prevention of stricture progression in the esophagus is the main aim of the treatment for corrosive esophageal burns. We aimed to investigate the protective and anti-inflammatory effects of methylene blue (MB) treatment on corrosive esophageal burns. METHODS: Twenty-eight rats were used in the study and randomly divided into four equal groups; group 1 (Sham), group 2 (control), group 3 (topical treatment), and group 4 (topical plus systemic treatment). Except for group 1 (Sham group), all three groups received sodium hydroxide (NaOH) in order to generate esophageal burns. In addition, group 2 was given normal saline, group 3 topical MB, and group 4 topical and systemic MB. RESULTS: Hydroxyproline levels were found to be lower in each of the treatment groups as compared to the control group (p=0.005 for group 3 and p=0.009 for group 4). There were no differences in the tumor necrosis factor-α (TNF-α) levels between the groups. The stenosis index (SI) in the treatment groups was also lower than the control group (p=0.016 for group 3 and p=0.015 group 4). The histopathologic damage score (HDS) was prominently lower in group 4 as compared to the control group (p=0.05). CONCLUSION: MB is effective in treating tissue damage caused by corrosive esophageal burns and in preventing esophageal stenosis. Complication rates of corrosive esophageal burns may be decreased by using MB in the initial treatment stage. Keywords: Caustic burn; corrosive esophageal burn; methylene blue; stenosis index; TNF-α.

INTRODUCTION Corrosive esophageal burns, that mostly happen accidentally in children, constitute a serious problem across different age groups and are relatively common in rural areas and developing countries.[1] Corrosive esophageal burns are caused by alkaline substances in 90% of cases and by acidic substances in the remaining 10%.[2] Alkaline substances are easily acces-

sible since they are used for cleaning, soap making, or fruit drying. The amount, concentration, and structure of the compound be it liquid or solid and the duration of the contact between the product and esophageal mucosa plays a critical role in the severity of the injury. The complications seen after the ingestion may vary from acute esophageal perforation to chronic

Cite this article as: Şen Tanrıkulu C, Tanrıkulu Y, Kılınç F, Bahadır B, Can M, Köktürk F, et al. The protective and anti-inflammatory effect of methylene blue in corrosive esophageal burns: An experimental study. Ulus Travma Acil Cerrahi Derg 2019;25:317-323. Address for correspondence: Yusuf Tanrıkulu, M.D. KTO Karatay Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, 42020 Konya, Turkey Tel: +90 332 - 221 00 00 E-mail: drtanrikulu@hotmail.com Ulus Travma Acil Cerrahi Derg 2019;25(4):317-323 DOI: 10.5505/tjtes.2018.58506 Submitted: 28.06.2018 Accepted: 16.11.2018 Online: 08.07.2019 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

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Şen Tanrıkulu et al. The protective and anti-inflammatory effect of MB in corrosive esophageal burns

fibrosis leading to strictures.[3–5] The aims of the treatment for corrosive esophageal burns are to improve wound healing, prevent perforation, and reduce stricture formation. There is a close connection between the severity of the initial injury and the stricture formation, which is a significant complication of corrosive esophageal burns. Therefore, the initial treatment may play a game-changing role in preventing the development of strictures.[6–8] Since stricture formation is a consequence of the inflammation and fibrosis that occurs during wound healing, medical treatment should focus on reducing the wound inflammation.[9] Although many agents, including retinoic acid, pentoxifylline, sucralfate, N-acetylcysteine, antibiotics, and steroids have been used in both clinical and experimental studies to prevent the development of strictures, only antibiotics and steroids have gained clinical application.[10–13] MB was first identified as an antimalarial agent by Ehrlich in 1981, and it has since been used in many different areas of clinical medicine including treatment of refractory distributive shock, renal stones, carbon monoxide poisoning, methemoglobinemia, and encephalopathy for years due to its low toxicity and wide availability.[14,15] Most recently, MB was described as an effective product for preventing postoperative adhesions as well. Although the mechanism is unknown, the anti-adhesive effect of MB may depend on the reduction of the anti-inflammatory products caused by trauma and antioxidant effects, such as the inhibition of the effect of nitric oxide (NO) and activation of fibrinolytic activity.[16,17] Based on the literature describing the anti-adhesive effect of MB, we aimed to investigate the effect of MB treatment on corrosive esophageal burns.

MATERIALS AND METHODS Study Design and Animals Each experiment was performed based on the National Guidelines for The Use and Care of Laboratory Animals after obtaining the approval of the Animal Ethics Committee of Bulent Ecevit University (number: 2014/12). Twenty-eight male adult Wistar-Albino rats, weighing 250±30 g, were housed individually under constant temperature (21±1 °C) in wire cages with 12-hour light-dark cycles, fed a standard diet, and given water ad libitum. The animals were deprived of food from 12 hours before anesthesia. However, no water restriction was done until 2 hours before anesthesia. No enteral or parenteral antibiotics were administered at any time.

Experimental Model The experimental corrosive esophageal burns were induced according to the model described by Gehanno et al.[18] in 1981. All the animals were sedated using 80 mg/kg ketamine hydrochloride (KetalarR; Parke-Davis, Istanbul, Turkey) and 20 mg/kg xylazine (RompunR, Bayer, Istanbul, Turkey) intramuscularly. In this study, a 1.5 cm distal esophageal segment 318

was used to administer the burns. Following a median laparotomy, a five Fr catheter was inserted through the mouth and placed into the distal esophagus. To prevent the escape of the solution directly into the stomach or into the respiratory tract by aspiration, the cardio-esophageal junction and proximal esophagus were tied with 2/0 silk. A solution of 0.1 mL of 37.5% sodium hydroxide (NaOH) was administered for 90 seconds and then aspirated. Next, the burned segments were washed using distilled water for 30 seconds. After cutting the sutures, the gastric insertion sites were also repaired. Following the closure of the laparotomy, 10 mL of 0.9% saline was administered intraperitoneally, and the rats were made to fast for the next 24 hours. The treatment of the study groups started on the first postoperative day. The rats were observed under standard laboratory conditions by feeding standard food and water ad libitum during the treatment period. No rats died during the experiment.

Experimental Groups Twenty- eight rats were randomly divided into four groups (7 rats in each group): Group 1 (Sham): A corrosive esophageal burn was not created after laparotomy. A 0.1 mL dose of saline was administered intraperitoneally to each rat as a single daily dose for ten days. Group 2 (Control): A corrosive esophageal burn was created after laparotomy. A 0.1 mL dose of saline was administered intraperitoneally to each rat as a single daily dose without any treatment for ten days and the esophageal lumen was washed with a 0.1 mL dose of saline. Group 3 (Topical Treatment): A corrosive esophageal burn was created after laparotomy. After washing the esophageal lumen with saline, a 0.1 mL dose of 1% MB was administered topically to the esophageal lumen. The rats were placed in the reverse Trendelenburg position for 30 minutes to provide sufficient mucosal contact with the drug. Later, a 0.1 mL dose of saline was administered intraperitoneally to each rat as a single daily dose for ten days. Group 4 (Topical+Systemic Treatment): A corrosive esophageal burn was created after laparotomy. After washing the esophageal lumen with saline, a 0.1 mL dose of 1% MB was administered topically to the esophageal lumen. The rats were placed in the reverse Trendelenburg position for 30 minutes to provide sufficient mucosal contact with the drug. Later, a 0.1 mL dose of 1% MB was administered intraperitoneally to each rat as a single daily dose for ten days.

Histopathological Evaluation One well-experienced pathologist who was blinded to the study design evaluated each specimen. For this evaluation, 2 cm distal esophagus sections were taken. A solution of 10% Ulus Travma Acil Cerrahi Derg, July 2019, Vol. 25, No. 4


Şen Tanrıkulu et al. The protective and anti-inflammatory effect of MB in corrosive esophageal burns

neutral formaldehyde was used to fix the esophageal tissue samples and followed by the paraffin embedding technique. Tissue samples of 4 μm thickness were stained using hematoxylin-eosin (H&E) and then analyzed under a light microscope (Olympus BX53, Tokyo, Japan). Stenosis index (SI) was chosen to assess the degree of stenosis of the esophageal lumen in our study. For this evaluation, esophageal wall thickness was measured in two different areas from the mucosal surface to the connective tissue outside the muscularis propria using a millimetric ocular microscope and the average of the two measurements was calculated (A0 = [A1+A2]/2). The lumen diameters were also measured in two different areas along a straight line, and the average of the two measurements was obtained (B0 = [B1+B2]/2). The SI was calculated as follows: SI = (wall thickness [A0])/lumen diameter [B0]).[19]

pharm, Hangzhou) as described in the instruction book. First, the samples, standards, and streptavidin-HRP were added to the well. The antibodies were labeled with an enzyme and the plate was incubated for 60 minutes at 37ºC. The plate was washed five times and chromogen solutions were added. The plate was incubated for 10 minutes at 37ºC and the stop solution was added into the wells. The optical density (OD) was measured under 450 nm wavelengths with a microplate reader. According to standards concentration, the corresponding OD values were calculated using the standard curve linear regression equation to calculate the corresponding sample’s concentration.

Statistical Analysis

The histopathologic damage score (HDS) was used to determine the degree of damage and collagen accumulation in the esophageal wall. The tissues were scored on a scale in three different categories for a total score of 0–5 (Table 1).[20] For this evaluation, the sections obtained from the paraffin-embedded tissue were stained with Masson’s trichrome in order to evaluate changes in the connective tissue.

SPSS (Statistical Package for Social Science) for Windows 19.0 package program was used to analyze the results. The onesample Kolmogorov-Smirnov test was performed for data normality and then for continuous variables, the KruskalWallis variance analysis was used. The continues variables were given as the mean ± standard deviation. Dunn’s test was used as the post hoc test after the Kruskal-Wallis test. Noncontinuous variables were expressed as the median (minmax). To compare non-continuous variables, the Chi-Square test was used. A p-value of less than 0.05 was considered statistically significant for all tests.

Biochemical Analysis

RESULTS

The spectrophotometric method was used to detect tissue hydroxyproline concentrations and the results were given as micrograms per milligram of tissue.[21] The serum TNF-α levels were assessed using the Rat TNF-α ELISA kit (EastbioTable 1. Histopathological evaluation criteria Criteria Score Increase in submucosal collagen None

Mild (submucosal collagen at least twice the

thickness of muscularis mucosa)

Severity (submucosal collagen more than twice

the thickness of muscularis mucosa)

0 1 2

Damage to the muscularis mucosa None

1

Present

2

Damage and collagen deposition in tunica muscularis None

Mild (collagen deposition around the

smooth muscle fibers)

Severity (same as mild with collagen

deposits replacing some muscle fibers)

Ulus Travma Acil Cerrahi Derg, July 2019, Vol. 25, No. 4

0 1 2

The comparison of the levels of hydroxyproline and TNF-α among the groups are summarized in Table 2. The levels of hydroxyproline were significantly lower in the treatment groups than in group 2 (p=0.005 for group 3 and p=0.009 for group 4). The levels of TNF-α were lower in the treatment groups than in group 2, however, these differences were not statistically significant (p=0.413 for group 3 and p=0.444 for group 4). The comparison between the esophageal stenosis assessments among the groups is given in Table 3. There were no differences between the groups in terms of lumen diameters. The control group did not show a narrowing of the lumen diameter but showed an increase in wall thickness. The wall thicknesses in the treatment group were lower than in group 2; wall thickness in the group that systemically received MB was closer to the sham group; and there was a difference in wall thickness between group 4 and group 2 (p=0.023), but there was no difference between group 3 and group 2 (p=0.687). According to the SI, there were differences between the treatment group and group 2 (p=0.016 for group 3 and p=0.015 group 4). The comparisons of the histopathological evaluations between groups are summarized in Table 3 and Fig. 1. HDS was chosen as the method of evaluation in our study and was used to evaluate the increase in collagen deposition in the submucosal area and tunica muscularis and the destruction 319


Şen Tanrıkulu et al. The protective and anti-inflammatory effect of MB in corrosive esophageal burns

Table 2. The comparison of the levels of hydroxyproline and TNF-α between groups Groups

Hydroxyproline (μg/mg)

TNF-α (ng/L)

Group 1 (SHAM)

0.74±0.19c 24.64±9.24

Group 2 (control)

3.20±0.52

Group 3 (topical treatment)

0.75±0.33 42.29±8.26

Group 4 (topical+systemic treatment)

0.76±0.43b 43.97±4.87

53.93±8.87x

a

p=0.005, bp=0.009 and cp=0.013 vs. group 2, xp<0.001 vs. group 1.

a

Table 3. The comparison of the histopathological evaluation results between groups Groups

Wall thickness (μ)

Stenosis index

Total histopathologic score

Group 1 (SHAM)

0.74±0.27

0.42±0.12x

0 (0–1)*

Group 2 (control)

1.13±0.14

0.72±0.17

3 (2–3)

Group 3 (topical treatment)

0.88±0.19

0.44±0.12

1 (0–2)

Group 4 (topical+systemic treatment)

0.70±0.14a 0.39±0.09z

1 (0–1)#

y

p=0.023 vs. group 2, xp=0.032, yp=0.016 and zp=0.015 vs. group 2, *p=0.005 and #p=0.019 vs. group 2.

a

of muscularis mucosa. Sham group showed a normal histologic state and lumen diameter. Other groups showed variable rates of inflammatory cells in the esophagus wall with characterized reactions. There were no differences between the groups in the increase of submucosal collagen (p=0.210). Damage to the muscularis mucosa was significantly lower in group 4 than group 2 (p=0.043 and p=0.026, respectively), but there was no difference between group 2 and group 3. The total HDS was significantly lower in group 4 than in group 2 (p=0.019) (Fig. 1).

DISCUSSION There are many experimental and clinical investigations regarding the treatment of esophageal burns in the literature. However, there are no effective and safe agents to administer the said treatment. Although MB is used effectively in many other areas of medicine, there are almost no studies on its effects on corrosive esophageal burns. This study revealed the protective and anti-inflammatory effects of MB on esophageal burns.

(a)

(b)

(c)

(d)

(e)

(f)

(g)

(h)

Figure 1. The sham group appears to have normal esophagus histology, lumen diameter, and wall thickness (a, b). The control group has contained focal inflammation cells that remove the epithelium (c). Muscularis mucosa and tunica muscularis are thickened, also the submucosal collagen is slightly increased (d). Topically treatment group (Group 3) has a normal lumen diameter (e) and deposition of collagen in the submucosa and muscularis tunica (f). Systemically treatment group (Group 4) appears to have normal lumen diameter and wall thickness (g). There was no histological damage except for a slight increase of collagen in the submucosa (h). In the Masson Trichrome figures; star shows the tunica muscularis layer, the arrow submucosal layer, and the triangle muscularis mucosa layer. For a, c, e, and g H&E with x40 magnification; for b, d, f, and h Masson Trichrome with magnification x100 is used.

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Ingestion of caustic substances is a serious problem that causes corrosive esophagitis in the acute necrotic phase and stricture formation in the long-term. Therefore, the key to reducing these complications is a very good understanding of the pathophysiology. The level of damage varies based on the type of tissue affected, the amount of ingested substance, the period of contact, the type of agent (acid and alkali), and the physical structure (solid or liquid) of the caustic substance.[4] Alkaline substances cause liquefaction necrosis, while acidic substances cause coagulation necrosis that is mostly limited to the mucosa.[22] The acute necrotic phase occurs during the first 1-4 days following the injury and is characterized by decreased perfusion of the tissue, increased lipid peroxidation, hydrolysis, and reactive oxygen radicals and the beginning of the inflammatory reaction. Following the subacute phase, scar formation related to fibroblast proliferation and stricture formation related to collagen accumulation may occur.[12,22] The medical treatment needs to reduce the inflammation because the degree of the acute inflammatory reaction plays the most important role in stricture formation.[23] The current management protocol for corrosive esophagitis is still limited to antibiotics, steroids, and neutralization in the acute phase, although there are many other treatment methods that vary according to the phase and the severity of the damage.[9] To reduce inflammation and collagen synthesis and to prevent fibroplasia and stricture formation, numerous studies have been performed to evaluate the medical efficiency of antioxidant and anti-inflammatory agents such as sucralfate, palifermin, dimethyl sulfoxide, prednisolone, retinoic acid, zinc, trimetazidine, and pentoxifylline.[9–13,22,23] Despite the decreased stricture formation demonstrated in these studies, the rate of stricture formation is still 70–100% in high-grade corrosive esophagitis.[9] MB, a nontoxic and safe dye, has both anti-adhesive and antiinflammatory properties. Although the main mechanism of action of MB is unknown, the primary effect of MB inhibits guanylate cyclase by targeting NO. The anti-adhesive effects of MB may depend on the reduction of the anti-inflammatory products caused by trauma and antioxidant effects such as inhibition of the effect of NO and the activation of the fibrinolytic activity.[17,24] In addition, MB shows immunomodulatory effect by the expression of adhesion molecules on endothelial cells. MB reduced TNF production by 50% and inhibited the systemic and local inflammation.[25] The main effect of MB in inflammation has not been fully clarified as of today and its mechanism should be analyzed further. Besides the anti-inflammatory effects of MB, it has antioxidant effects as well. In contrast to classic antioxidants like vitamin E, MB has a direct inhibitory effect on endogenous NADPH.[26] On reviewing the literature, several studies can be found on the effect of MB. One of them was conducted by Kilincaslan et al.,[27] who found that MB applied locally might reduce the tissue damage in corrosive esophagitis because of its antioxUlus Travma Acil Cerrahi Derg, July 2019, Vol. 25, No. 4

idant effects. In their studies on adhesions, Kalaycı et al.[17] and Dinc et al.[16] found that while MB may prevent peritoneal adhesions, it could wound healing could be impaired. In a randomized retrospective study conducted by Gümürdülü et al.,[9] it was found that the prevalence of stricture formation could be reduced with sucralfate treatment. Howell et al.[28] found that treatment of corrosive esophagitis with steroids decreased the frequency of stricture formation. In their study comparing beta-aminopropionitrile (BAPN) and prednisolone, Aciksari et al.[13] found that BAPN was able to decrease the development of stenosis and tissue damage better than prednisolone. Şen Tanrıkulu et al.[29] found that garlic oil is an effective agent in promoting the regression of esophageal stenosis and tissue damage caused by corrosive burns. In another study,[23] investigators found that dimethyl sulfoxide may decrease the severity of tissue damage. In addition to inflammation, oxidative stress has a key role in increased tissue damage. It was shown that reactive oxygen radicals increased during the early phase of esophageal burns and that NaOH treatment increased lipid peroxidation.[19,30] In corrosive esophageal burns, while SI and HDS are the most important indicators of esophagus damage, the levels of hydroxyproline are an indicator of collagen accumulation. These indicators are used to demonstrate the esophageal stricture and to evaluate the efficacy of therapeutic agents.[11] In our study, we examined SI and HDS to evaluate esophageal damage, levels of hydroxyproline to evaluate collagen accumulation, and levels of TNF-α to evaluate the anti-inflammatory effect. We found that the levels of hydroxyproline were lower in the treatment groups than in the control group. Although the levels of TNF-α were lower in the treatment groups than in group 2, the differences were not significant. In addition, we found that there were differences in the SI results between treatments groups and the control group. The total HDS was significantly lower in group 4 than the control group (p=0.019). Unfortunately, the current results hardly suggest that we use MB in a clinical setting. In this rat model, we applied a constant quantity of MB to the esophageal lumen via a catheter. In reality, the clinical use of MB is poorly understood. MB is mostly used as 10 mg/ml in the form of an ampoule as a pharmaceutical treatment for several diseases such as methemoglobinemia.[31] In the daily clinical routine, MB doses of up to 7 mg/ kg have been used in humans in case of shock.[32] The highest acceptable dose of MB is 9 mg/kg.[33] Although the optimal dose of this dye is not known, based on the present study results we concluded that a volume of 1% of MB may reduce the level of stenosis. Finally, the ingestion of commercial bulb forms containing methylene blue per orally can be suggested after corrosive ingestion.

Conclusions In this study, we found that MB administered topically and/ or systemically was an effective agent to treat tissue damage 321


Şen Tanrıkulu et al. The protective and anti-inflammatory effect of MB in corrosive esophageal burns

caused by corrosive burns and to prevent esophageal stenosis. This beneficial effect was more pronounced with systemic treatment. However, a significant anti-inflammatory effect of MB was not detected. We believe that the use of MB during the initial emergency clinic treatment of patients with corrosive esophageal burns could reduce complications such as stenosis and strictures. To assess the medical application of MB, further comprehensive clinical studies are required.

Acknowledgments Thanks are due to the employees of the operating room and the department of pathology. Ethics Committee Approval: Ethics committee approval was received for this study from the Ethics Committee of Bulent Ecevit University Faculty of Medicine numbered 2014/12. Financial Disclosure: The authors declared that this study has received no financial support. Conflict of interest: None declared.

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12. Somuncu S, Cakmak M, Erdogan S, Caglayan O, Akman H, Kaya M. Trapidil, an inhibitor for phosphodiesterase and platelet-derived-growth factor, ameliorates corrosive esophageal burn in rats. Tohoku J Exp Med 2005;207:203−8. 13. Aciksari K, Yanar HT, Hepgul G, Ozucelik DN, Yanar F, Agcaoglu O, et al. The effect of Beta-aminopropionitrile and prednisolone on the prevention of fibrosis in alkali esophageal burns: an experimental study. Gastroenterol Res Pract 2013;2013:574260. 14. Wainwright M, Crossley KB. Methylene Blue--a therapeutic dye for all seasons? J Chemother 2002;14:431−43. 15. Clifton J 2nd, Leikin JB. Methylene blue. Am J Ther 2003;10:289−91. 16. Dinc S, Ozaslan C, Kuru B, Karaca S, Ustun H, Alagol H, et al. Methylene blue prevents surgery-induced peritoneal adhesions but impairs the early phase of anastomotic wound healing. Can J Surg 2006;49:321−8. 17. Kalaycı MU, Eroğlu HE, Kubilay D, Soylu A, Sancak B, Uğurluoğlu C, et al. The effects of methylene blue on adhesion formation in a rat model of experimental peritonitis. Ulus Travma Acil Cerrahi Derg 2011;17:205−9. 18. Gehanno P, Guedon C. Inhibition of experimental esophageal lye strictures by penicillamine. Arch Otolaryngol 1981;107:145−7. 19. Berthet B, di Costanzo J, Arnaud C, Choux R, Assadourian R. Influence of epidermal growth factor and interferon gamma on healing of oesophageal corrosive burns in the rat. Br J Surg 1994;81:395−8. 20. Ocakci A, Coskun O, Tumkaya L, Kanter M, Gurel A, Hosnuter M, et al. Beneficial effects of Ebselen on corrosive esophageal burns of rats. Int J Pediatr Otorhinolaryngol 2006;70:45−52. 21. Bergman I, Loxley R. Two improved and simplified methods for the spectrophotometric determination of OH-proline. Anal Chem 1963;35:1961−5. 22. Numanoğlu KV, Tatli D, Bektaş S, Er E. Efficacy of keratinocyte growth factor (palifermin) for the treatment of caustic esophageal burns. Exp Ther Med 2014;8:1087−91. 23. Kilincaslan H, Ozbey H, Olgac V. The effects of dimethyl sulfoxide on the acute phase of experimental acid and alkali corrosive esophageal burns. Eur Rev Med Pharmacol Sci 2013;17:2571−7. 24. Raghavendran K, Davidson BA, Helinski JD, Marschke CJ, Manderscheid P, Woytash JA, et al. A rat model for isolated bilateral lung contusion from blunt chest trauma. Anesth Analg 2005;101:1482−9. 25. Culo F, Sabolović D, Somogyi L, Marusić M, Berbiguier N, Galey L. Anti-tumoral and anti-inflammatory effects of biological stains. Agents Actions 1991;34:424−8. 26. Montz FJ, Holschneider CH, Bozuk M, Gotlieb WH, Martinez-Maza O. Interleukin 10: ability to minimize postoperative intraperitoneal adhesion formation in a murine model. Fertil Steril 1994;61:1136−40. 27. Kilincaslan H, Karatepe HO, Kilic E, Aydogdu I, Gedik AH, Olgac V, et al. Beneficial effects of methylene blue on the acute phase of corrosive esophageal burn in rats. Eur J Pediatr Surg 2015;25:299−304. 28. Howell JM, Dalsey WC, Hartsell FW, Butzin CA. Steroids for the treatment of corrosive esophageal injury: a statistical analysis of past studies. Am J Emerg Med 1992;10:421−5. 29. Şen Tanrıkulu C, Tanrikulu Y, Kılınç F, Bahadır B, Can M, Köktürk F. Beneficial effects of garlic (Allium sativum) oil in experimental corrosive esophageal burns effects of garlic oil in esophageal burns. Ulus Travma Acil Cerrahi Derg 2017;23:181−7. 30. Günel E, Cağlayan F, Cağlayan O, Akillioğlu I. Reactive oxygen radical levels in caustic esophageal burns. J Pediatr Surg 1999;34:405−7. 31. Evora PR, Ribeiro PJ, Vicente WV, Reis CL, Rodrigues AJ, Menardi AC, et al. Methylene blue for vasoplegic syndrome treatment in heart surgery: fifteen years of questions, answers, doubts and certainties. Rev Bras Cir Cardiovasc 2009;24:279−88. 32. Salaris SC, Babbs CF, Voorhees WD 3rd. Methylene blue as an inhibitor of superoxide generation by xanthine oxidase. A potential new drug for

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33. Windholz M, Budavari S. The Merck index: an encyclopedia of chemicals, drugs, and biologicals. 10th ed. Rahway, NJ: Merck&Co,1983.

DENEYSEL ÇALIŞMA - ÖZET OLGU SUNUMU

Korozif özefagus yanıklarında metilen mavisinin koruyucu ve anti-enflamatuvar etkisi: Deneysel çalışma Dr. Ceren Şen Tanrıkulu,1 Dr. Yusuf Tanrıkulu,2 Dr. Fahriye Kılınç,3 Dr. Burak Bahadır,4 Dr. Murat Can,5 Dr. Fürüzan Köktürk,6 Dr. Ayşe Kefeli7 Sağlık Bilimleri Üniversitesi, Konya Eğitim ve Araştırma Hastanesi, Acil Tıp Anabilim Dalı, Konya KTO Karatay Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Konya 3 Necmettin Erbakan Üniversitesi Tıp Fakültesi, Patoloji Anabilim Dalı, Konya 4 Bülent Ecevit Üniversitesi Tıp Fakültesi, Patoloji Anabilim Dalı, Zonguldak 5 Bülent Ecevit Üniversitesi Tıp Fakültesi, Biyokimya Anabilim Dalı, Zonguldak 6 Bülent Ecevit Üniversitesi Tıp Fakültesi, Biyoistatistik Anabilim Dalı, Zonguldak 7 Gaziosmanpaşa Üniversitesi Tıp Fakültesi, Gastroenteroloji Bilim Dalı, Tokat 1 2

AMAÇ: Gelişmekte olan ülkelerde daha sık görülen ve korozif madde yutulmasına bağlı oluşan özefageal yanıkları kısa dönemde özefagus perforasyonuna ve uzun dönemde darlık oluşmasına neden olmaktadır. Korozif özefagus yanıklarında tedavinin asıl amacı özefagusta darlık oluşumunu önlenmektir. Biz, bu çalışmada korozif özefagus yanıklarının tedavisinde metilen mavisinin (MB) antienflamatuvar ve koruyucu etkisini araştırmayı amaçladık. GEREÇ VE YÖNTEM: Çalışmada 28 sıçan kullanıldı ve sıçanlar rastgele dört eşit gruba ayrıldı; 1. grup (Sham), 2. grup (kontrol), 3. grup (topikal tedavi) ve 4. grup (topikal ve sistemik tedavi). Sham grubu hariç diğer gruplara özefageal yanık oluşturmak için sodyum hidroksit (NaOH) verildi. Ek olarak, ikinci gruba normal salin, 3. gruba topikal metilen mavisi ve 4. gruba topikal ve sistemik metilen mavisi verildi. BULGULAR: Hidroksiprolin seviyeleri her bir tedavi grubunda kontrol grubuna göre daha düşüktü (p=0.005 grup 3’e göre, p=0.00 grup 4’e göre). Tümör nekrozis faktör-α seviyelerine göre gruplar arasında fark yoktu. Tedavi gruplarına ait stenoz indeksleri kontrol grubuna göre daha düşüktü (p=0.016 grup 3’e göre, p=0.015 grup 4’e göre). Histopatolojik hasar skoru kontrol grubu ile karşılaştırıldığında grup 4’te belirgin olarak daha düşüktü (p=0.05). TARTIŞMA: Metilen mavisi korozif özefageal yanıkların neden olduğu doku hasarını tedavi etmede ve özefageal stenozu önlemede etkilidir. Korozif özefageal yanıklardaki komplikasyon oranları yanık esnasında kullanılan metilen mavisi ile azaltılabilir. Anahtar sözcükler: Metilen mavisi; korozif özefagus yanığı; kostik yanık; stenoz indeksi; TNF-α. Ulus Travma Acil Cerrahi Derg 2019;25(4):317-323

doi: 10.5505/tjtes.2018.58506

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323


EXPERIMENTAL STUDY

Comparison of the effects of two different marine-derived omega-3 fatty acid sources, krill oil, and fish oil, on the healing of primary colonic anastomoses after colectomy applied Wistar albino rat model Murat Ferhat Ferhatoğlu, M.D.,1 Taner Kıvılcım, M.D.,1 Gürcan Vural, M.D.,2 Abdulcabbar Kartal, M.D.,1 Ali İlker Filiz, M.D.,1 Abut Kebudi, M.D.1 1

Department of General Surgery, İstanbul Okan University Faculty of Medicine, İstanbul-Turkey

2

Department of Pathology, İstanbul Okan University Faculty of Medicine, İstanbul-Turkey

ABSTRACT BACKGROUND: Oils from marine organisms have a different fatty acid composition. Fish oil (FO) has a high content of eicosapentaenoic and docosahexaenoic acids esterified to triacylglycerols; while in krill oil (KO), fatty acids are primarily esterified to phospholipids. This study aimed to compare the efficacy of two different, marine-derived omega-3 fatty acid sources in the wound healing of colon anastomoses rat model. METHODS: For the study, we used 42 male Wistar albino rats. The rats were divided into six groups with seven rats in each group— CO3: left colonic anastomosis (control group), sacrificed on the third day; KO3: left colonic anastomosis + oral KO, sacrificed on the third day; FO3: left colonic anastomosis + oral FO, sacrificed on the third day; CO7: left colonic anastomosis (control group), sacrificed on the seventh day; KO7: left colonic anastomosis + oral KO, sacrificed on the seventh day; FO7: left colonic anastomosis + oral FO, sacrificed on the seventh day. Peritoneal adhesions, anastomotic bursting pressures, hydroxyproline levels, and histological examination of the anastomotic tissue were evaluated. RESULTS: On day 7, bursting pressure and hydroxyproline measurements of the KO group was significantly higher than the FO group (p=0.012; p=0.002, respectively). Also, on day 7, a statistically significant difference was observed between the groups according to inflammatory cell infiltration, fibroblast activity, neoangiogenesis, and collagen deposition in favor of the KO group (p=0.023; p=0.028; p=0.016; p=0.012, respectively). CONCLUSION: Both KO and FO supplementation in patients before colorectal surgery may reduce some risk of anastomotic leakage; and KO might be a better alternative and excellent omega-3 source. Keywords: Anastomotic healing; fish oil; krill oil; omega-3 fatty acids; primary colonic anastomosis.

INTRODUCTION Fish oil (FO) is a rich source of long-chain n-3 polyunsaturated fatty acids, eicosapentaenoic acid, and docosahexaenoic acid.[1] The overall fatty acid composition of krill oil (KO) resembles that of FO, same docosahexaenoic acid content but

higher eicosapentaenoic acid. FO comprises the majority of these fatty acids as triglycerides, whereas 30%–65% of the fatty acids are stored as phospholipids in KO.[2] Whether being esterified in triglycerides or phospholipids effects on the absorption efficiency of fatty acids into the blood and on the impact on serum lipid levels are controversial issues.

Cite this article as: Ferhatoğlu MF, Kıvılcım T, Vural G, Kartal A, Filiz Aİ, Kebudi A. Comparison of the effects of two different marine-derived omega-3 fatty acid sources, krill oil, and fish oil, on the healing of primary colonic anastomoses after colectomy applied Wistar albino rat model. Ulus Travma Acil Cerrahi Derg 2019;25:324-330. Address for correspondence: Murat Ferhat Ferhatoğlu, M.D. Istanbul Okan Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, 34734 Tuzla, İstanbul, Turkey Tel: +90 216 - 677 16 30 E-mail: ferhatferhatoglu@yahoo.co.uk Ulus Travma Acil Cerrahi Derg 2019;25(4):324-330 DOI: 10.14744/tjtes.2019.03051 Submitted: 13.03.2019 Accepted: 24.06.2019 Online: 08.07.2019 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

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Ferhatoğlu et al. Krill and fish oil on the healing of colonic anastomoses

The fourth most common cause of cancer deaths worldwide is colorectal cancer,[3] and anastomosis leakage is one of the most severe complications of colorectal surgery. Despite the recent advances in surgical techniques and technologic devices, the anastomosis leakage occurs in up to 37% of patients with colorectal cancer.[4] Most anastomoses are performed as a part of the treatment of colorectal cancer. After resection of the cancer, an anastomosis is made if it is found feasible and safe. Besides colorectal anastomosis, gastrointestinal anastomoses are performed in many other fields of gastrointestinal surgery as well.[5] Gastric and esophageal anastomoses are performed in the treatment of gastroesophageal cancer and obesity, pancreatico-jeonunal anastomoses in the treatment of pancreatic cancer, and biliary anastomoses in the treatment of benign as well as malignant diseases in the hepatobiliary system. The number of anastomoses in these fields is widely unknown.[6,7] Anastomotic leakage is also a feared complication in these fields of surgery, and as in colorectal surgery, the consequences for the patients are severe. Previous studies have shown that patients should receive a diet rich in long-chain polyunsaturated fatty acids to enhance the safety of anastomosis.[8,9] The effect of long-chain n-3 polyunsaturated fatty acids esterified to phospholipids dietary support on the mechanical and inflammatory events surrounding anastomosis healing has never been determined. This study aimed to investigate the effect of immediate longchain n-3 polyunsaturated fatty acids supports on colonic anastomotic healing in Wistar albino rat model.

MATERIALS AND METHODS Animals: The researchers used 42 male Wistar albino rats with a mean weight of 284–367 g obtained from the Biological Experiments with Living Animals Laboratory of Uskudar University, Istanbul, Turkey. The rats were maintained on a regular laboratory rat diet (crude protein: 23%, crude fat: 3.0%, crude fiber: 7.0%, acid insoluble ash: 8%, calcium: 1%– 2.5%, phosphorus: 0.9%, sodium: 0.5%–1%, moisture: 12%. Ingredients: corn, soybean pulp, sunflower seed meal, shorts, Bonquality flour, alfalfa pellets, molasses, meat and bone meal, poultry meal, sepiolite, inorganic DCP, marble dust, vitamins, minerals) and tap water with a 12-h day/night light cycle at a room temperature of 24°C–26°C. We formed six groups containing seven rats in each group. The rats were housed as two per cage and allowed to mobilize freely. Randomization: Rats were randomized into groups using computer-generated random numbers. None of the animals died during the study. For the study, six groups were formed as follows: CO3 (n=7) left colonic anastomosis (control group), sacrificed on the third day (KO or FO was not administrated); KO3 (n=7) left colonic anastomosis + KO, sacrificed on the third day; FO3 (n=7), left colonic anastomosis + FO, sacrificed on the third day; CO7 (n=7) left colonic anastomoUlus Travma Acil Cerrahi Derg, July 2019, Vol. 25, No. 4

sis (control group) sacrificed on the seventh day (KO or FO was not administrated); KO7 (n=7) left colonic anastomosis + KO, sacrificed on the seventh day; FO7 (n=7), left colonic anastomosis + FO, sacrificed on the seventh day. Omega-3 sources: One red krill oil capsule (iHealht, Dikilitas/Istanbul): KO 500 mg + eicosapentaenoic acid 66 mg + docosahexaenoic acid 35 mg + coline 25 mg + astaxanthin 40 mg, 2- EFA 1200 capsule (Sifar İlac, Fenerbahce/Istanbul): eicosapentaenoic acid 396 mg + docosahexaenoic acid 264 mg+ other fatty acids 60 mg.

Application of Omega-3 Sources KO3 and KO7: Thirty days before surgery, KO3 and KO7 received KO emulsion as an isocaloric and isovolumetric emulsion at a dose of 100 mg/kg/day eicosapentaenoic acid (1.8 ml/kg/day red krill oil capsule) through a rigid orogastric tube. On the 30th day, the study begins; the KO feeding of the rats was stopped. FO3 and FO7: Thirty days before surgery, FO3 and FO7 received FO emulsion as an isocaloric and isovolumetric emulsion at a dose of 100 mg/kg/day eicosapentaenoic acid (0.25 ml/kg/day EFA 1200 capsule) through a rigid orogastric tube. On the 30th day, the study begins; the FO feeding of the rats was stopped. Surgical procedure: All rats were fasted for 8 h before surgery that was performed under sterile conditions by a surgeon who is uninformed about experimental groups. A veterinary who is an expert on biological experiments administrated general anesthesia with 50 mg/kg ketamine hydrochloride (Ketamine, Pfizer, New York, USA) intraperitoneally and 5 mg/kg xylazine hydrochloride (XYLAZINBIO 2%, Bioveta, Cankaya, Ankara, Turkey) intramuscularly. Next, the anterior abdominal wall was shaved with an electric razor and wiped with povidone-iodine to obtain antiseptic conditions. After sterile drape covering, uninformed surgeon exposed the peritoneal cavity with a 4-cm midline abdominal incision. After exploration of the abdominal cavity, the surgeon excluded the animals with gastrointestinal anomalies and intraabdominal tumors from the study. Following this elimination process, the surgeon performed a colo-colonic anastomosis. Left colon was mobilized, and a full-layer cut was created in a 90° angle to the longitudinal axis of the colon. Next, the surgeon performed an end-to-end colo-colic anastomosis using a using 6/0 non-absorbable, monofilament polypropylene inverting, six, sutures (Ethicon, Somerville, New Jersey, USA). After anastomosis, the surgeon closed the abdominal wall with 3/0 silk sutures (Dogsan, Besiktas, Istanbul, Turkey) and injected 10 ml/kg sterile saline subcutaneously for postoperative hydration at the end of the procedure. Animals were fasted for postoperative 24 h, after which they were initiated on a standard diet and drinking water (not including KO or FO). 325


Ferhatoğlu et al. Krill and fish oil on the healing of colonic anastomoses

Sacrification of rats: A veterinary who is an expert on biological experiments on animals sacrificed the rats using a guillotine. Evaluation of adhesions: Post-mortem examination was conducted to grade adhesions on a scale from 0 to 3 according to the method introduced by van der Ham et al.[10] Measurement of colonic anastomosis bursting pressure: The uninformed surgeon made bursting pressure measurements within 3 min of sacrifice. First, the anastomosis integrity was determined by exposing the anastomosis line and removal of the adhesions in the surrounding tissues. Next, two cuts, one 2 cm proximal and the other 2 cm distal to the anastomosis site, were made to obtain a 4-cm long colonic segment. Fecal content of the colon was removed with physiologic saline solution. The distal end of the removed colon segment was ligated with small titanium clip (Ethicon, Somerville, New Jersey, USA) after an infusion set connected to a sphygmomanometer was inserted into the proximal end of the colon segment. The surgeon put the excised part of the colon in a beaker filled with a physiological saline solution and inflated with air. The intraluminal pressure was increased in 10-mmHg increments and maintained for 10 s. The appearance of air bubbles was used to record the bursting pressure in mmHg. Notably, bursting occurred at the anastomosis line in all samples. The anastomosis leakage or dehiscence was determined if the bursting pressure of the resected colon segment was measured as 0 mmHg or if the significant findings of leakage/dehiscence (abscess formation in the peritoneal cavity) were observed; these animals were excluded from the study. Next, the anastomosis segment was cut longitudinally and divided into two half rings; one half was placed in 10% formalin solution for histopathological evaluation, and the other half was stored at −80°C for hydroxyproline measurement. Histopathological evaluation: The same pathologist who was blinded to the treatment groups sectioned the 10% formalin-fixed colonic segments, stained them with hematoxylin and eosin, and analyzed them with light microscopy at 200× magnification by. Infiltration of inflammatory cells (leukocyte count), the activity of fibroblast cells, neoangiogenesis, and collagen content were measured using the modified Ehrlich and Hunt scale by Phillips et al.[11] (0: no evidence, 1: occasional evidence, 2: light scattering, 3: abundant evidence, 4: confluent cells or fibers). Tissue hydroxyproline assay: The tissue concentrations of hydroxyproline, which represent perianastomotic collagen levels, were measured using the Rat hydroxyproline enzymelinked immunosorbent assay (ELISA) Kit (Bioassay Technology Laboratory, Shanghai, China, USA Cat. No E0511Ra). The values were expressed as nanogram amount of hydroxyproline per milliliter of tissue (ng/ml). The detection principle of Rat hydroxyproline ELISA kit: This experiment uses a double-sandwich ELISA tech326

nique and the ELISA kit provided is typical. The pre-coated antibody is rat hydroxyproline monoclonal antibody, and the detecting antibody is a polyclonal antibody with biotin-labeled. Samples and biotin labeling antibody are added into ELISA plate wells and washed out with 1.5 ml of phosphate buffered saline. Then avidin-peroxidase conjugates are added to ELISA wells in order; tetramethylbenzidine substrate is used for coloring after reactant is thoroughly washed out by phosphate buffered saline. Tetramethylbenzidine turns into blue in peroxidase catalytic and finally turns into yellow under the action of the acid. The color depth and the testing factors in samples are positively correlated. Power analysis: Power analysis was conducted using the G*Power (v3.1.9.2) program, to define the number of samples. The power of the study was confirmed as 1- (= probability of type II error) and was set at 80%. Based on the adhesion scores of previous studies,[12] estimated from abscess formation, significance at a minimum of 1 unit with 0.7 units of standard deviation (SD). The resultant calculated effect size was d=1.319. To obtain 20% type II error (power is 80%) at 0.05 level, it was decided to involve at least seven rats in each group.

Statistical Analysis For statistical analysis, the Number Cruncher Statistical System (NCSS) 2007 (Kaysville, Utah, USA) program was used. Descriptive statistical methods (mean, SD, median, frequency, ratio, minimum, maximum) were used when evaluating the study data. The Mann–Whitney U test was used to compare two groups of data that did not show normal distribution. Kruskal–Wallis test and Bonferroni–Dunn test were used in double comparisons. The Fisher–Freeman–Halton Exact test and Fisher’s Exact test were used to compare the qualitative data. The Wilcoxon signed ranks test was used for intragroup comparisons of non-normally distributed parameters. Significance was evaluated at least p<0.05. Ethical approval: This research followed the Guide for the Care and Use of Laboratory Animals published by the US National Research Council (Eight Edition 2010). Animal care was provided according to the standards proposed by the European Community (86/609/EEC). And the Istanbul, Uskudar University Board of Biological Experiments with Living Animals approved the experimental protocol (August 16, 2017-13).

RESULTS The weight of the rats while the beginning of the experiment ranged between 280 and 367 g (304.71±24.42). Macroscopic evaluation: No statistical difference was noticed according to groups on macroscopic evaluation parameters as anastomosis dehiscence/leakage, abscess formation in the peritoneal cavity. Moreover, adhesion score of KO7 was significantly lower than FO7 (p=0.01) (Table 1). Ulus Travma Acil Cerrahi Derg, July 2019, Vol. 25, No. 4


Ferhatoğlu et al. Krill and fish oil on the healing of colonic anastomoses

tamination in the abdominal cavity, fecal peritonitis, anastomotic dehiscence) were observed in two rats (CO3: 1, FO3: 1). Also, bursting pressures of two rats were measured as 0 mmHg (KO3: 1; FO7: 1), which was accepted as anastomotic leakage. Statistically significant differences were not found between the bursting pressure measurements of the control, KO and FO group on the third day (p=0.839). But bursting pressure measurements of KO-applied group was significantly higher than other groups on the seventh day (p=0.012).

Table 1. Evaluation of anastomosis dehiscence, intraabdominal abscess

Control

Krill oil Fish oil

n (%)

n (%)

7 (100)

p

a

n (%)

Anastomoses dehiscence 3rd day

No

6 (85.7)

Yes

1 (14.2)

0 (0)

1 (14.2)

7th day

No

7 (100)

7 (100)

7 (100)

Yes

0 (0)

0 (0)

0 (0)

b

6 (85.7) 1.000

Histological evaluation: The histological evaluation measurements are shown in Figure 1. Inflammatory cell infiltration rate of KO7 and FO7 was lower than CO7 (p=0.023). Fibroblast activity of FO3 is higher than KO3 and CO3 (p=0.03). But the fibroblast activity of KO-applied group was significantly higher on the seventh day. No significant difference was observed between the groups according to neoangiogenesis and collagen deposition measurements on the third day (p>0.05; p>0.05, respectively). Neoangiogenesis and collagen deposition measurements of the KO7 group was significantly higher than other groups (p=0.016; p=0.012, respectively).

1.000

p 0.559 0.192 0.462

Intra-abdominal abscess 3rd day

No

4 (66.6)

5 (71.4)

5 (83.3) 1.000

Yes

2 (33.3)

2 (28.6)

1 (16.7)

7th day

No

6 (85.7)

7 (100)

Yes

1 (14.3)

0 (0)

b

a

6 (85.7) 1.000 1 (14.3)

p 1.000 0.462 1.000

Fisher-Freeman-Halton Exact Test; bFisher’s Exact Test; *p<0.05; **p<0.01.

Bursting pressure values: Measurements of the bursting pressures of the anastomoses are demonstrated in Table 2. Significant anastomotic leakage suggestive findings (fecal con-

Hydroxyproline measurements: The anastomotic hydroxyproline measurements are shown in Table 3. Hydroxyproline measurements of KO3 and KO7 are higher than FO3 and FO7, but the difference is not statistically significant (p=0.404; p=0.219, respectively). Also, no statistically significant difference was observed between groups CO3, KO3,

Table 2. Evaluation of bursting pressure measurements

Control

Krill oil

0–30

0–12

Fish oil

p

a

Bursting pressure (mmHg) 3rd day

Minimum-maximum

Mean±SD

7th day

Minimum-maximum

Mean±SD

0–10

9.29±10.9 5.71±5.4 6.57±4.58 0.839 0–180

220–300

140–240

131.43±62

242.86±76.1

191.43±51.2

0.012*

p 0.014* 0.002** 0.002**

b

Kruskal Wallis Test; bMann-Whitney U Test; *p<0.05; **p<0.01. SD: Standard deviation.

a

Table 3. Evaluation of hydroxyproline measurements

Control

Krill oil

Fish oil

Minimum-maximum

0.2–1.9

0–7.2

0–1.4

Mean±SD

0.65±0.5 2.72±2.9 0.59±0.5

7th day

Minimum-maximum

Mean±SD

b

p

a

OH-proline*** (ng/ml) 3rd day

0–11.2

1.2–28.8

0.404

0.8–13.7

5.13±5.2 7.95±10 5.86±4.9 0.002**

p 0.014* 0.002** 0.002**

Kruskal Wallis Test; bMann-Whitney U Test; *p<0.05; **p<0.01; ***Hydroxyproline. SD: Standard deviation.

a

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(either KO or FO) decreases the inflammation on peritoneal surfaces in the critical stage of peritoneal wound healing.

CO3

KO3

FO3

CO7

KO7

Inflammatory cell infiltration

Fibroblast activity

Neoangiogenesis

Collagen deposition

FO7

Figure 1. The histological evaluation measurements.

and FO3 (p=0.404). However, hydroxyproline measurements of the KO7 group were significantly higher than the CO7 and FO7 groups.

DISCUSSION Our findings suggest that both FO and KO have a positive influence on wound healing following colon anastomosis. Moreover, KO has more positive effects on anastomotic healing than FO. Anastomotic leakage remains a challenge that is associated with morbidity and mortality in patients undergoing colorectal surgery.[13] Leakage at the site of anastomosis has been reported to contribute to an increase in the length of hospital stays and medical costs.[14–16] Prevention of anastomosis leakage remains the most critical issue. Hence, highlighting the need for new treatment strategies to prevent anastomosis leakage is crucial. Since the anastomotic strength is very limited in the first days of surgery, the risk of anastomotic dehiscence is utmost, even if the surgical process is performed under optimal circumstances.[12] Therefore, the early days of surgery are critical for anastomotic healing. Many investigators have researched on anastomotic wound healing process.[12,14,17–20] And these studies also investigated the effectiveness of diverse systemic or local applied agents on the anastomotic healing process.[17,21,22] Inflammation during wound healing process stimulates the formation of fibrous bands between serosal surfaces ultimately. [23] First seven days is the most critical time for peritoneal fibrous adhesion formation in the rat model.[12] Karakas et al.[24] demonstrated that the use of O3FA depresses intraperitoneal adhesion formation. The adhesion score of the KO groups is lower on the seventh day (p=0.01), which shows that the utilization of KO reduces adhesion/fibrous band formation around the anastomosis. Many agents have been used to forestall adhesion formation by delimitating inflammatory reactions during peritoneal healing, thereby reducing the creation of a fibrinous network between serosal surfaces.[12– 14,17,19,20] Although detecting the properties of KO that depress the formation of peritoneal adhesions may be an issue of another study, we think the administration of omega-3 sources 328

Neutrophils migrate into the wound in the beginning stages of the inflammatory reaction. Activation of neutrophils in wound healing process happens to be secondary to inflammatory mediators.[25] These inflammatory cytokines (TNF-α, IL-1, IL-6, and other) are high enough to be measured in the systemic circulation and much higher levels in the abdominal exudate.[26] Kuhn et al.[27] demonstrated that suppressing inflammatory cytokines promotes intestinal healing. Because of the inflammatory and chemo-attractant mediators secreted secondary to colonic injury/surgery, activated neutrophils either in systemic circulation or in peritoneal cavity readily accumulates around the anastomosis. This rapid accumulation boosts inflammatory reaction around the anastomosis that may disrupt the anastomotic healing if the collection is exaggerated.[12,28] In this study, control groups had more inflammatory cell infiltration. Similar to our results, other studies reported the O3FA to create an impairment over inflammatory cell migration, thus reducing the inflammatory reaction.[8,29] Fibroblast cells and neovascularization promote the synthesis of collagen and mucopolysaccharides to increase anastomotic strength.[30] Migration of endothelial cells begins on the second and third days of the inflammation, and this process is completed by the sixth or seventh day.[31] The fibrinopurulent exudates fill anastomotic space in peritoneal cavity. This fibrinopurulent exudates repress collagen and new blood vessel formation and, as a result, that the anastomosis heals by secondary intention.[32] Lobraico et al.[33] revealed that KO supplementation has a positive effect on endothelial function. Fahs et al.[34] also demonstrate the positive impact of FO supplementation on endothelial function. Zeng et al.[35] showed that O3FA attenuates the fibroblast cells. In this study, fibroblast activity and neoangiogenesis were higher in both KO-supplemented groups. We believe anti-inflammatory activity of n-3 polyunsaturated fatty acids, eicosapentaenoic acid, and docosahexaenoic acid promote the endothelial cell activity. In clinical practice, the physical strength of the anastomosis is not an ideal parameter to assess the healing of colonic anastomosis; nonetheless, bursting pressure was used as an indirect method to evaluate anastomotic integrity.[24] We found that bursting pressure of the animals treated with both KO and FO is higher than control groups, whereas there was no significant difference in the bursting pressures between the KO and FO groups on the third day. However, bursting pressure of the KO7 group was significantly higher (p=0.012). This result may be indirectly suggest that KO may provide an advantage over FO in ensuring anastomosis integrity. The most crucial factor in anastomotic healing is collagen, which forms the tensile strength of submucosal connective tissue.[36] Increased inflammation may cause excessive collagenolysis, and the anti-inflammatory function of O3FA might inhibit Ulus Travma Acil Cerrahi Derg, July 2019, Vol. 25, No. 4


Ferhatoğlu et al. Krill and fish oil on the healing of colonic anastomoses

collagenolysis during tissue healing.[37] Hydroxyproline levels can be used to assess collagen formation during wound healing. Hydroxyproline is a component of collagen that was shown to be positively correlated with the collagen amount and strength of anastomosis.[21] In this study, hydroxyproline levels were higher on day 7 compared to those on day 3 among all groups which are an expected result of the wound healing process. We also found that hydroxyproline levels of the KO-treated animals were higher than FO-treated animals (p=0.002). The higher level of hydroxyproline in the KO7 group may be a sign of a better collagen formation than the FO groups. These results suggest that both KO and FO might increase the strength of the anastomosis by inducing collagen formation, but KO may provide better anastomotic strength. And, KO and FO might also decrease collagenolysis via an anti-inflammatory action, but further investigations are needed on this issue. Collagen is an essential protein in all stages of the wound healing process. It is mandatory to ensure anastomotic integrity-strength for complete anastomotic healing.[38] The balance between pre-existing fibrillary collagen cleaved by matrix metalloproteinase 8 (synthesized by neutrophils, macrophages, and bacteria located in wound side) and de novo collagen synthesis composes wound collagen amount on first three days of wound healing. Although previous studies have shown de novo synthesis begins 10th hour of the tissue injury, new collagen synthesis reaches its maximal capacity on the fourth day of the surgery.[39] De novo synthesized collagen amount reaches a climax point between the fifth and seventh days after tissue damage, and this newly synthesized collagen maintains the integrity and strength of anastomosis.[12] For a reason explained above, we preferred to evaluate anastomotic tissue on the third and seventh days that exemplify the early and late phases of wound healing of anastomotic tissue. In this study, the collagen deposition levels and hydroxyproline measurements do not differ between KO and FO on the early and late phases of the anastomosis. But both values of the KO7 group are higher than the control and FO groups on the seventh day, which are other indirect signs of KO improving anastomotic strength and integrity by stimulating better collagen synthesis.

Limitations There were several limitations of our study. Although we tried to accommodate the number of rats using power analysis, the small sample size was the first limitation of our study. Another limitation was that the effect of FO and KO on colonic anastomosis was evaluated only under normal condition without disease activity. Thus, our study failed to reflect the real clinical experience. Finally, the marine-derived oil metabolism in rats is unknown and may differ from humans. Despite these limitations, we assumed that our study well demonstrated solely the effect of KO and FO on colonic anastomotic healing.

Conclusion Our experimental investigation has shown that both KO and Ulus Travma Acil Cerrahi Derg, July 2019, Vol. 25, No. 4

FO supplementation in patients before colorectal surgery may reduce some risk factors of anastomotic leakage by improving endothelial functions, neoangiogenesis, de novo collagen synthesis, and reducing excessive inflammation. Compared to the wound healing of colon anastomosis, KO is better than FO. We also concluded that KO might be a new alternative and preferable omega-3 source. Conflict of interest: None declared.

REFERENCES 1. Ulven SM, Holven KB. Comparison of bioavailability of krill oil versus fish oil and health effect. Vasc Health Risk Manag 2015;11:511−24. 2. Tou JC, Jaczynski J, Chen YC. Krill for human consumption: nutritional value and potential health benefits. Nutr Rev 2007;65:63−77. 3. Bhandari A, Woodhouse M, Gupta S. Colorectal cancer is a leading cause of cancer incidence and mortality among adults younger than 50 years in the USA: a SEER-based analysis with comparison to other young-onset cancers. J Investig Med 2017;65:311−5. 4. Neumann PA, Twardy V, Becker F, Geyer C, Schwegmann K, Mohr A, et al. Assessment of MMP-2/-9 expression by fluorescence endoscopy for evaluation of anastomotic healing in a murine model of anastomotic leakage. PLoS One 2018;13:e0194249. 5. Nordentoft T. Sealing of gastrointestinal anastomoses with fibrin glue coated collagen patch. Dan Med J 2015;6:B5081. 6. Kofoed SC, Calatayud D, Jensen LS, Jensen MV, Svendsen LB. Intrathoracic anastomotic leakage after gastroesophageal cancer resection is associated with reduced long-term survival. World J Surg 2014;38:114−9. 7. Rutegård M, Lagergren P, Rouvelas I, Lagergren J. Intrathoracic anastomotic leakage and mortality after esophageal cancer resection: a population-based study. Ann Surg Oncol 2012;19:99−103. 8. Terzi C, Sevinç AI, Koçdor H, Oktay G, Alanyali H, Küpelioğlu A, et al. Improvement of colonic healing by preoperative rectal irrigation with short-chain fatty acids in rats given radiotherapy. Dis Colon Rectum 2004;47:2184−94. 9. Ekçi B, Karabicak I, Atukeren P, Altinlio E, Tomaoglu K, Tasci I. The effect of omega-3 fatty acid and ascorbic acid on healing of ischemic colon anastomoses. Ann Ital Chir 2011;82:475−9. 10. van der Ham AC, Kort WJ, Weijma IM, van den Ingh HF, Jeekel H. Effect of antibiotics in fibrin sealant on healing colonic anastomoses in the rat. Br J Surg 1992;79:525−8. 11. Phillips JD, Kim CS, Fonkalsrud EW, Zeng H, Dindar H. Effects of chronic corticosteroids and vitamin A on the healing of intestinal anastomoses. Am J Surg 1992;163:71−7. 12. Uludag M, Citgez B, Ozkaya O, Yetkin G, Ozcan O, Polat N, et al. Effects of amniotic membrane on the healing of primary colonic anastomoses in the cecal ligation and puncture model of secondary peritonitis in rats. Int J Colorectal Dis 2009;24:559−67. 13. Holmer C, Praechter C, Mecklenburg L, Heimesaat M, Rieger H, Pohlen U. Anastomotic stability and wound healing of colorectal anastomoses sealed and sutured with a collagen fleece in a rat peritonitis model. Asian J Surg 2014;37:35−45. 14. Daglioglu YK, Duzgun O, Sarici IS, Ulutas KT. Comparison of platelet rich plasma versus fibrin glue on colonic anastomoses in rats. Acta Cir Bras 2018;33:333−40. 15. Ersoz N, Ozler M, Topal T, Uysal B, Poyrazoglu Y, Simsek K, et al. Effects of ozone treatment on experimental colon anastomosis in rats. Eur Surg 2016;48:122−8. 16. Strunden MS, Heckel K, Goetz AE, Reuter DA. Perioperative fluid and volume management: physiological basis, tools and strategies. Ann Intensive Care 2011;1:2.

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Ferhatoğlu et al. Krill and fish oil on the healing of colonic anastomoses 17. Kiyama T, Onda M, Tokunaga A, Yoshiyuki T, Barbul A. Effect of early postoperative feeding on the healing of colonic anastomoses in the presence of intra-abdominal sepsis in rats. Dis Colon Rectum 2000;43:S54−8. 18. Aebi H. Catalase in vitro. Methods Enzymol 1984;105:121−6. 19. Barlas AM, Kuru S, Kismet K, Cavusoglu T, Bag YM, Senes M, et al. Rectal application of argan oil improves healing of colorectal anastomosis in rats1. Acta Cir Bras 2018;33:565−76. 20. Yamada F, Endo N, Miyatake S, Ebisu G, Hino K. Enteral feeding with low-methoxyl pectin accelerates colonic anastomosis healing in rats. Nutrition 2018;45:94−8. 21. Cancan G, Teksoz S, Aytac E, Arikan AE, Erman H, Uzun H, et al. Effects of Ankaferd on anastomotic healing of colon. J Invest Surg 2014;27:1−6. 22. Ersoy OF, Ozkan N, Ozsoy Z, Kayaoglu HA, Yenidogan E, Celik A, et al. Effects of melatonin on cytokine release and healing of colonic anastomoses in an experimental sepsis model. Ulus Travma ve Acil Cerrahi Derg. 2016;22:315−21. 23. Mutsaers SE, Prêle CM, Pengelly S, Herrick SE. Mesothelial cells and peritoneal homeostasis. Fertil Steril 2016;106:1018−24. 24. Karakas DO, Yigitler C, Gulec B, Kucukodaci Z, Ipcioglu OM, Akin ML. Comparison of 4 % icodextrin and omega 3 Fatty acids in prevention of peritoneal adhesions. Indian J Surg 2014;76:181−6. 25. Koh TJ, DiPietro LA. Inflammation and wound healing: the role of the macrophage. Expert Rev Mol Med 2011;13:23. 26. Zhu P, Liang Z, Fu J, Chen W, Wang Z, Jiang H, et al. Procalcitonin in abdominal exudate to predict prolonged postoperative ileus following colorectal carcinoma surgery. Int J Biol Markers 2013;28:187−91. 27. Kuhn KA, Manieri NA, Liu TC, Stappenbeck TS. IL-6 stimulates intestinal epithelial proliferation and repair after injury. PLoS One 2014;9:114195. 28. Teke Z, Aytekin FO, Aydin C, Kabay B, Yenisey C, Sacar S, et al. Effects of pyrrolidine dithiocarbamate on healing of colonic anastomoses in the cecal ligation and puncture model of intraperitoneal sepsis in rats. World J Surg 2007;31:200−9. 29. Vigerust NF, Bjørndal B, Bohov P, Brattelid T, Svardal A, Berge RK. Krill oil versus fish oil in modulation of inflammation and lipid metabolism in

mice transgenic for TNF-α. Eur J Nutr 2013;52:1315−25. 30. Mariggiò MA, Cassano A, Vinella A, Vincenti A, Fumarulo R, Lo Muzio L, et al. Enhancement of fibroblast proliferation, collagen biosynthesis and production of growth factors as a result of combining sodium hyaluronate and aminoacids. Int J Immunopathol Pharmacol 2009;22:485−92. 31. Oguido APMT, Hohmann MSN, Pinho-Ribeiro FA, Crespigio J, Domiciano TP, Verri WA Jr, et al. Naringenin Eye Drops Inhibit Corneal Neovascularization by Anti-Inflammatory and Antioxidant Mechanisms. Invest Ophthalmol Vis Sci 2017;58:5764−76. 32. Saravanan M. A Comparative Study Between Single Versus Double Layered Intestinal Anastomosis. The Tamil Nadu Dr. M.G.R. Medical University Chennai 2015;600:032. 33. Lobraico JM, DiLello LC, Butler AD, Cordisco ME, Petrini JR, Ahmadi R. Effects of krill oil on endothelial function and other cardiovascular risk factors in participants with type 2 diabetes, a randomized controlled trial. BMJ Open Diabetes Res Care 2015;3:e000107. 34. Fahs CA, Yan H, Ranadive S, Rossow LM, Agiovlasitis S, Wilund KR, et al. The effect of acute fish-oil supplementation on endothelial function and arterial stiffness following a high-fat meal. Appl Physiol Nutr Metab 2010;35:294−302. 35. Zeng Z, Yang H, Wang Y, Ren J, Dai Y, Dai C. Omega-3 Polyunsaturated Fatty Acids Attenuate Fibroblast Activation and Kidney Fibrosis Involving MTORC2 Signaling Suppression. Sci Rep 2017;7:46146. 36. Adam AB, Özdamar MY, Esen HH, Günel E. Local effects of epidermal growth factor on the wound healing in esophageal anastomosis: An experimental study. Int J Pediatr Otorhinolaryngol 2017;99:8−12. 37. Curioni CC, Alves NNR, Zago L. Omega-3 supplementation in the treatment of overweight and obese children and adolescents: A systematic review. J Func Food 2019;52:340−7. 38. Rieger H, Kruschewski M, Khalilullah F, Buhr HJ, Pohlen U. Bursting pressure, vascular integrity and collagen content of sutured and glued colorectal anastomoses in the rat model. 7th World Congress on Trauma, Shock, Inflammation and Sepsis 2007;125−30. 39. Wilgus TA, Roy S, McDaniel JC. Neutrophils and Wound Repair: Positive Actions and Negative Reactions. Adv Wound Care (New Rochelle) 2013;2:379−88.

DENEYSEL ÇALIŞMA - ÖZET OLGU SUNUMU

Deniz kaynaklı, iki farklı omega-3 yağ asidi kaynağının, krill yağı ve balık yağı, primer kolon anastomozlarının iyileşmesi üzerindeki etkilerinin kolektomi uygulanan Wistar albino sıçan modeli ile karşılaştırılması Dr. Murat Ferhat Ferhatoğlu,1 Dr. Taner Kıvılcım,1 Dr. Gürcan Vural,2 Dr. Abdulcabbar Kartal,1 Dr. Ali İlker Filiz,1 Dr. Abut Kebudi1 1 2

İstanbul Okan Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İstanbul İstanbul Okan Üniversitesi Tıp Fakültesi, Patoloji Anabilim Dalı, İstanbul

AMAÇ: Deniz canlılarından gelen yağların farklı yağ asidi bileşimleri vardır. Balık yağı (FO), triasilgliserollere esterlenmiş yüksek oranda eikosapentaenoik ve dokosahekssaenoik asit içeriğine sahipken, krill yağında (KO) yağ asitleri temel olarak fosfolipidlere esterlenir. Bu çalışmada, iki farklı, omega-3 yağ asidi kaynağının kolon anastomozu uygulanan sıçan modelinde, anastomoz iyileşmesindeki etkinliğini karşılaştırdık. GEREÇ VE YÖNTEM: Çalışmada 42 erkek Wistar albino sıçan kullanıldı. Yedi sıçandan oluşan altı grup şu şekilde oluşturuldu: CO3: Üçüncü günde sakrifiye edilen sol kolon anastomu yapılan sıçan (kontrol grubu); KO3: Üçüncü günde sakrifiye edilen sol kolon anastomozu yapılan sıçan + oral KO; FO3: Üçüncü günde sakrifiye edilen sol kolon anastomozu yapılan sıçan + oral FO; CO7: Yedinci günde sakrifiye sol kolon anastomozu yapılan sıçan (kontrol grubu); KO7: Yedinci günde sakrifiye edilen sol kolon anastomozu yapılan sıçan + oral KO; FO7: Yedinci günde sakrifiye edilen sol kolon anastomozu yapılan sıçan + oral FO. Peritoneal adezyonlar, anastomoz patlama basınçları, hidroksiprolin düzeyleri ve anastomotik dokunun histolojik özellikleri değerlendirildi. BULGULAR: Kril yağı grubunun patlama basıncı ve hidroksiprolin ölçümleri, yedinci günde FO grubundan anlamlı olarak daha yüksekti (sırasıyla, p=0.012; p=0.002). Ayrıca, enflamatuvar hücre infiltrasyonuna, fibroblast aktivitesi, neoanjiyogenez ve kollajen birikimine göre gruplar arasında, yedinci günde KO grubu lehine istatistiksel olarak anlamlı bir fark gözlendi (sırasıyla, p=0.023; p=0.028; p=0.016; p=0.012). TARTIŞMA: Kolorektal cerrahi öncesi hastalara hem KO hem de FO desteği anastomoz kaçağı riskini azaltabilir ancak KO daha iyi bir omega-3 kaynağı olarak öne çıkmaktadır. Anahtar sözcükler: Anastomoz iyileşmesi; balık yağı; krill yağı; omega-3 yağ asitleri; primer kolon anastomozu. Ulus Travma Acil Cerrahi Derg 2019;25(4):324-330

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doi: 10.14744/tjtes.2019.03051

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EXPERIMENTAL STUDY

Relationship between arterial oxygen tension and mortality of patients in intensive care unit on mechanical ventilation support Ayhan Kaydu, M.D.,1

Günseli Orhun, M.D.,2

Nahit Çakar, M.D.3

1

Department of Anesthesiology and Reanimation, Diyarbakır Selahaddi̇ n Eyyubi State Hospital, Diyarbakır-Turkey

2

Department of Anesthesiology and Reanimation, İstanbul University Faculty of Medicine, İstanbul-Turkey

3

Department of Anesthesiology and Reanimation, Koç University Faculty of Medicine, İstanbul-Turkey

ABSTRACT BACKGROUND: Although there are studies demonstrating hyperoxia may be an independent risk factor for increased mortality and morbidity, this issue remains unclear. Our research then aimed to examine the relationship between arterial oxygen tension, arterial carbon dioxide tension, and in-hospital mortality of critically ill patients in intensive care unit (ICU). METHODS: After obtaining ethics committee approval, we analyzed a retrospective data of patients over the age of 18 who survived at least 24 hours in the ICU on mechanical ventilatory support between year 2008 and 2012. The demographic properties, mechanical ventilation, and blood gas parameters were studied. We defined hyperoxia group as PaO2 value of ≥120 mmHg and normoxemia group as PaO2 of 60–120 mmHg. Patients with PaCO2 value <30 mmHg were determined to have hypocapnia, those with 30–50 mmHg normocapnia, and those with >50 mmHg hypercapnia. RESULTS: Between 2008 and 2012, a total of 7689 patients were admitted to the ICU. Of 450 patients meeting the inclusion criteria of the study, 263 (58.4%) were male and 187 (41.6%) were female. Normoxia was observed in 232 (51.5%) patients and hyperoxia in 218 (48.5%) patients. The mean PaO2 was 16.2 kPa (121.50 mmHg), and FiO2 was 60%. 254 (56%) of the patients had died during the five-year period. There was no statistically significant difference in mortality between PaO2 levels and PCO2 levels (p>0.05). According to the classification of PaO2 and FiO2, there was no statistically significant difference in mortality (p>0.05) among patients. In addition, no statistically significant difference was found between the survival rates according to PCO2 classification (p=0.602, p>0.05). CONCLUSION: There was no significant association between mortality and oxygen and carbon dioxide of patients in ICU on mechanical ventilatory support. Keywords: Hyperoxia; intensive care unit; mechanical ventilation; normoxia; oxygen toxicity.

INTRODUCTION Oxygen is one of the most frequently used therapeutic agents in the clinical settings worldwide. However, healthcare professionals, even in developed countries, have paid little attention with respect to its indications for potential use, dosage, concentrations required for administration, duration of administration, side effects, and toxicity.[1] It was toward the end of the 19th century that the use of oxygen became widespread in the treatment of diseases. Paul Bert and Lorrain Smith[2]

reported that oxygen at high concentrations could lead to toxicity. As shown in several animal experiments and a limited number of human studies, the administration of high doses of oxygen can cause deleterious systemic effects on other organ systems, such as the lungs, brain, and heart.[3–6] Although there are studies which have shown that hyperoxia increased morbidity and mortality,[7] there are also studies highlighting its benefits.[8–10] Currently, oxygen administered to patients is

Cite this article as: Kaydu A, Orhun G, Çakar N. Relationship between arterial oxygen tension and mortality of patients in intensive care unit on mechanical ventilation support. Ulus Travma Acil Cerrahi Derg 2019;25:331-337. Address for correspondence: Ayhan Kaydu, M.D. Diyarbakır Selahaddin Eyyubi Devlet Hastanesi, Anesteziyoloji ve Reanimasyon Kliniği, Diyarbakır, Turkey Tel: +90 412 - 228 54 30 E-mail: akaydu@hotmail.com Ulus Travma Acil Cerrahi Derg 2019;25(4):331-337 DOI: 10.5505/tjtes.2018.51430 Submitted: 12.10.2018 Accepted: 17.12.2018 Online: 09.07.2019 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

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Kaydu et al. Partial arterial oxygen pressure and mortality

considered as a “drug”.[11] Despite there appear studies on the exposure time and concentration of oxygen in the body, no clear guidelines have emerged yet on this subject.[12,13] The administration of oxygen therapy to critically ill patients is a complex process with many barriers, and it has been shown that the majority of applications have been made without sufficient evidence.[14–16] Studying the role of oxygen toxicity in patients who are on mechanical ventilation is even more of a challenge. In a retrospective study of 50 intensive care units (ICUs), de Jonge et al.[17] examined the relationship between mortality and arterial oxygen pressure in patients on mechanical ventilation support, and high mortality rates were observed in patients with high FiO2. They found that both low and high PaO2 increased mortality rates in the first 24 hours in ICU.[17] In a recent similar study by Eastwood et al.[18] hypoxia increased mortality, but no finding was reported suggesting that hyperoxia increased mortality. The primary aim of our study was to explore the relationship between arterial oxygen tension and mortality of patients in the intensive care unit on mechanical ventilation support, high or low PaO2 in the first 24 hours being associated with mortality. Then we examine the relationship between arterial carbon dioxide tension and in-hospital mortality of patients requiring mechanical ventilation support.

MATERIALS AND METHODS Ethical Approval The study was granted approval by the Ethics Committee of İstanbul University Medical Faculty (Registry Url: 2011/1790790 in accordance with the Code of Ethics of the World Medical Association-Declaration of Helsinki).

Inclusion Criteria Our ICU is a tertiary level unit with a total of 17 beds, comprising four isolation rooms and 13 beds in the open area. The inclusion criteria were patients aged over 18 years who received mechanical ventilator support from the time of admission and had arterial blood gas analyses in the ICU. Patients with severe burns or following cardiac surgery were not included in our study.[17] We have also excluded those with incomplete records of blood gas values, APACHE II score with diagnosis on admission, or SOFA score.

Data Collection From the patient records, the demographic characteristics (age, gender), date of admittance to ICU, length of stay in ICU, diagnosis causing ICU admittance, comorbidities, and blood gas values (provided it was arterial blood gas) within the first 48 hours in ICU were noted on a protocol form prepared with 6-hour sections. The values were examined from the blood gas values at 6-hour intervals, including the PaO2 (arterial oxygen pressure), PaCO2 (arterial carbon diox332

ide pressure), mechanical ventilation mode, PEEP (positive end-expiratory pressure), PAP (peak airway pressure), MAP (mean airway pressure), FiO2 (inspired oxygen concentration), number of sections where FiO2 decreased or increased, and the PaO2/FiO2 ratio. To explore the relationship between arterial oxygen pressures and mortality, the arterial blood gas selection model described in the study by Eastwood et al.[18] was used. Based on this model, if the FiO2 value is at least and more than 0.5, the PaO2 value was taken as the value at the time of the highest alveolar arterial gradient (A-a), and if the FiO2 value was <0.5, the worst PaO2 value was taken. In case the FiO2 values taken in the first 24 hours were both less than 0.5 and at least and more than 0.5, then the blood gas parameter was used to define as the “worst” PaO2. Following data preparation protocols, the patients were separated into two groups according to the PaO2 values. Group 1 was the normoxemic group with a PaO2 value of 60–120 mmHg and Group 2 was the hyperoxemic group with a PaO2 value of ≥120 mmHg. Hypocapnia, normocapnia, and hypercapnia were established by taking the mean value of the PCO2 parameter throughout the follow-up period and examining these values. Patients with PaCO2 value <30 mmHg were determined to have hypocapnia, those with 30–50 mmHg normocapnia, and those with >50 mmHg hypercapnia.

Statistical Analysis The statistical analyses of the study findings were made by the Number Cruncher Statistical System 2007 and Power Analysis and Sample Size 2008 Statistical Software (Utah, USA) programs. Descriptive statistical methods such as the mean value, standard deviation [SD], median, and rate were used. In the comparison of quantitative data between two groups showing normal distribution of the parameters, the Student’s t-test was applied, and for parameters not showing normal distribution, the Mann-Whitney U-test was employed. For comparison of qualitative data, the Continuity Correction (Yates) chi-square test and the Pearson chi-square test were used. The Kaplan-Meier analysis and the log rank test were applied to perform survival analysis. The results were evaluated with a 95% confidence interval. A value of p<0.05 was accepted as statistically significant.

RESULTS 450 out of 7689 patients admitted to the ICU between 2008 and 2012 who met the inclusion criteria were recruited, comprising 263 (58.4%) males and 187 (41.6%) females. The mean age of the patients was 59.60±16.96 years (range: 18–93 years). The general characteristics of the patients according to mortality are shown in Table 1. The mean age of the nonsurvivor patients was observed to be statistically significantly higher than Ulus Travma Acil Cerrahi Derg, July 2019, Vol. 25, No. 4


Kaydu et al. Partial arterial oxygen pressure and mortality

Table 1. General characteristics of patients according to mortality

Mortality

p

Survivors (n=195)

Non-survivors (n=254)

57.70±18.04

61.05±15.99

1

Intensive care unit stay (days), mean±SD (median)

17.31±14.6 (13)

13.99±15.28 (9)

2

0.001**

APACHE, Mean±SD (median)

18.38±6.39 (18)

24.61±5.99 (24)

2

0.001**

Simplified Acute Physiology Score II, mean±SD

39.44±13.09

52.24±15.88

1

Total mechanical ventilatory time (days), mean±SD (median)

10.7±9.71 (8)

13.01±12.78 (9)

2

0.87±2.73 (0.8)

2.05±3.98 (1.5)

2

0.001**

2.62±3.36 (2)

6.19±5.33 (5)

2

0.001**

Male, n (%)

111 (56.9)

151 (59.4)

Female, n (%)

84 (43.1)

103 (40.6)

Age (years), mean±SD

Renal replacement therapy (days), mean±SD (median) Inotrope (days), mean±SD (median)

1

0.042*

0.001** 0.048*

0.590

3

Student t-test; 2Mann-Whitney U test; 3Pearson Ki-Kare test; *p<0.05; **p<0.01. SD: Standard deviation.

Table 2. The diagnoses of the patients on admission to ICU according to in-hospital mortality

Table 3. The blood gas parameters of the patients according to mortality

Mortality

Mortality p

Survivors Non-survivors (n=195) (n=254)

Survivors Non-survivors (n=195) (n=254)

n % n %

Mean±SD Mean±SD

Cardiovascular

68 34.9 87 34.4 30.915

PaO2

p

122.07±59.37 115.92±46.89 10.221

Diabetes mellitus 38 19.5 61 24.0 0.251

FiO2

Hypertension

62 31.8 87 34.3 30.584

PaO2/FiO2 218.82±97.81 213.67±98.90 10.583

Respiratory

30 15.4 41 16.2 0.814

Renal

21 10.8 33 13.0 30.473

Gastrointestinal

5 2.6 20 7.9 30.026*

Malignancy

30 30 48 18.9 30.001**

Hematological

6 3.1 35 13.8 0.001

Neurological

20 10.3 25 9.8 41.000

Other

9 4.6 7 2.8 0.426

3

3

4

**

4

Pearson Ki-Kare test; Yates Contiunity Correctin test; p<0.05; p<0.01. ICU: Intensive care unit. 3

1 0.59±0.19 0.60±0.18 0.741

4

*

**

Student t-test. SD: Standard deviation.

1

Table 4. The evaluation of mortality according to PaO2 classifications Mortality PaO2 p

Normoxia Hyperoxia (n=231) (n=218)

Survivors

n % n % 102 44.2 93 42.7 0.749

that of the survivors (p<0.05). It was found that the length of stay in ICU of the survivor group was statistically significantly longer than that of the nonsurvivor group (p<0.01). The total duration of mechanical ventilation, the renal replacement therapy (RRT) days, and the duration of vasopressor agent administration were also higher in the nonsurvivor group than the survivor group. The APACHE II scores and the SAPS II levels were statistically significantly higher in the nonsurvivor group than in the survivor group (p<0.01).

the group transferred from clinics within the same hospital (p<0.01), and the discharge rate was determined to be higher in the group transferred postoperatively from the operating theater (p<0.01).

No statistically significant relationship was found between mortality and the place from where the patient was admitted to ICU. The exitus rate was statistically significantly higher in

The diagnoses of the patients on admission to ICU according to mortality are shown in Table 2. No statistically significant difference was determined between the admission diagnoses

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Non-survivors 129 55.8 125 57.3 Pearson chi-squared test.

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Table 5. The evaluation of mortality according to PaO2 classifications PaO2

p

Normoxia (n=232)

Hyperoxia (n=218)

60.03±15.71

59.14±1.26

1

0.581

Intensive care unit stay (days), mean±SD (median)

15.65±14.36 (11)

15.17±15.78 (10)

2

0.189

APACHE, Mean±SD (median)

22.22±6.95 (22)

21.58±6.82 (21)

2

0.347 0.857

Age (years) (mean±SD)

46.54±15.48

46.81±16.59

1

Simplified Acute Physiology Score II, mean±SD

12.55±12.71 (9)

11.4±10.24 (8)

2

0.371

Renal replacement therapy (days), mean±SD (median)

1.37±3.36 (0)

1.71±3.71 (0)

2

0.078

Inotrope (days), mean±SD (median)

4.39±4.86 (3)

4.89±4.94 (4)

2

0.188

Male, n (%)

140 (60.3)

123 (56.4)

3

0.399

Female, n (%)

92 (39.7)

95 (43.6)

Total mechanical ventilatory time (days), mean±SD (median)

1

Student t-test; 2Mann-Whitney U test; 3Pearson Chi-squared test. SD: Standard deviation.

Table 6. The standardized mortality rate according to PaO2 and FiO2 classifications in nonsurvivor group Non-survivors

SMR p

Mean SD

PaO2 (mmHg)

60–80

0.69

80–100 0.61 0.18

100–120 0.67 0.18

≥120

FiO2

0.21–0.40 0.59 0.19 0.367

0.41–0.60 0.64 0.19

0.61–0.80 0.65 0.20

0.81–1.0 0.77 0.12

0.16

0.170

0.62 0.20

Kruskal Wallis test. SMR: Standardized mortality ratio according to SAPS II; SD: Standard deviation.

and mortality rate (p>0.05) except in patients admitted for gastrointestinal, malignancy, and hematological diagnoses (p<0.05). The evaluation of the worst values and the mean values throughout the follow-up period of the blood gas parameters of the patients according to mortality is shown in Table 3. In the first 24 hours in ICU, the mean PaO2 was determined as 16.2 kPa (122.44+31.8 mmHg) and mean FiO2 as 60%. The PaO2 was 115.92±46 mmHg in the nonsurvivor group and the PaO2 was 122.07±59.37 mmHg in the survivor group. Furthermore, no significant difference was found between the two groups. The evaluation of mortality according to PaO2 classification (p>0.05) is presented in Table 4. It has been shown that there is no statistically significant difference between the survivor and nonsurvivor groups in respect of mortality. 334

No statistically significant difference was also seen in the length of stay in ICU, APACHE score, SAPS II, total duration of mechanical ventilation and RRT day, inotropic agent day, or gender in accordance with the PaO2 classification (p>0.05) (Table 5). The survival rates of the normoxia and hyperoxia groups were evaluated using the log rank test. It can be noticed that there was no statistically significant difference between the two groups (p=0.506, p>0.05) (Fig. 1). No statistically significant difference was observed between the standardized mortality rates (SMRs) according to PaO2 classification (p>0.05) and FiO2 classification (p>0.05) (Table 6). Hypocapnia (PCO2 <30 mmHg) was determined in 36 (8%) patients, normocapnia (PCO2 30–50 mmHg) in 354 (78.7%), and hypercapnia (PCO2 >50 mmHg) in 60 (13.3%) patients. It further revealed no statistically significant difference in mortality between patients as per the PCO2 classifications (p>0.05) (Table 7). When the survival rates of the hypocapnia, normocapnia, and hypercapnia groups were assessed with the log rank test, they have also shown no statistically significant difference (p=0.602, p>0.05) (Fig. 2).

DISCUSSION The aim of this study was to examine the relationship between mortality and the arterial oxygen pressure and arterial carbon dioxide pressure values measured during the conducted follow-up of patients on mechanical ventilator support in ICU. From the results of this study, the following conclusions were reached: 1. No significant relationship was determined between inhospital mortality and the arterial oxygen pressure values of the first and second 24 hours. Ulus Travma Acil Cerrahi Derg, July 2019, Vol. 25, No. 4


Kaydu et al. Partial arterial oxygen pressure and mortality

Table 7. Characteristics of patients according to PCO2 classifications PCO2 p

Hypocapnia (n=36)

Normocapnia (n=354)

Hypercapnia (n=60)

63.34±12.89

59.27±17.51

59.15±15.64

5

0.330

ICU stay (days), mean±SD (median)

13.58±11.49 (10)

15.32±14 (11)

17.1±21.63 (10)

6

0.774

APACHE, mean±SD (median)

22.56±7.39 (23)

21.79±6.76 (21)

22.25±7.42 (22)

6

0.661

Age (years), mean±SD

49.11±15.77 (45.5)

46.18±15.88 (45)

48.1±16.96 (48.5)

5

Total MV Time (days), mean±SD (median)

SAPS II, mean±SD

9.83±6.81 (8)

11.95±11.13 (9)

13.55±15.72 (9)

6

0.764

RR (days), mean±SD (median)

2.58±5.39 (0)

1.45±3.37 (0)

1.4±3.03 (0)

6

0.201

Inotrope (days), mean±SD (median)

5.22±4.68 (4)

4.61±4.83 (4)

4.42±5.43 (3)

6

0.408

3

Male, n (%)

27 (75.0)

203 (57.3)

33 (55.0)

Female, n (%)

9 (25.0)

151 (42.7)

27 (45.0)

Survivors, n (%)

13 (37.1)

158 (44.6)

24 (40.0)

Non-survivors, n (%)

22 (62.9)

196 (55.4)

36 (60.0)

0.440

0.104 0.589

3

Oneway ANOVA test; 6Kruskal Wallis test; 3Pearson Ki-Kare test. ICU: Intensive care unit; SAPS II: Simplified Acute Physiology Score; MV:Mechanical ventilatory; RR: Renal replacement therapy; SD: Standard deviation.

5

2. No significant relationship was determined between inhospital mortality and the arterial carbon dioxide values. There have been conflicting reports on the subject of the relationship between hyperoxia and mortality in studies which have examined the relationship between arterial oxygen values and mortality in patients on mechanical ventilator support. [17–20] However, our study has obtained similar results with Eastwood et al.[18] concerning the relationship between oxygen pressure and mortality in patients on mechanical ventilator support. In their study, while there was a significant relationship between hypoxia and mortality, no relationship was established between hyperoxia and mortality. The methodology utilized by Eastwood et al.[18] found a correlation between the PaO2 values on admittance to ICU and the peak PaO2 values in the first 24 hours. In our study, the same methodology was used in determining the worst PaO2 value in the first 24 hours. Despite similar statistical results in the two studies of mean

PaO2 (15.1 vs. 16.2 kPa) and FiO2 values (62% vs. 60%), a significant difference was found between the mortality values (26% vs. 56%). The reason for this difference could be that in the Eastwood et al. study, there were a greater number of patients being monitored in the ICU following elective surgery and the mortality of this patient group is known to be low. The SAPS II score evaluating the severity of the disease was determined to be higher (46.7 vs. 43.1) in our study compared to that of Eastwood et al. A similar study carried out by de Jonge[17] revealed that mortality increased with high FiO2, low PaO2, and high PaO2 values in the first 24 hours in ICU. The common ground between our study and that of de Jonge et al. was the determination of high FiO2 (50.4% vs. 60%) and high PaO2 (13.1 kPa vs. 16.2 kPa) in the first 24 hours. It has been indicated that there was a significant difference in the mortality rates of patients (23% vs. 56%) and there may be several reasons for this difference. The results could have been affected by the different methodologies used in determining the worst PaO2

Survival Functions

Survival Functions PaO2 Normoxia Hyperoxia Normoxiacensored Hyperoxiacensored

Cum Survival

0.8 0.6 0.4

1.0

PCO2 Hypoxia Normoxia Hyperoxia Hypoxiacensored Normoxiacensored Hyperoxiacensored

0.8 Cum Survival

1.0

0.6 0.4 0.2

0.2

0.0 0.0

0 0

20

40 60 80 ICU stay (days)

100

120

Figure 1. The survival rates of the normoxia and hyperoxia groups.

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20

40 60 80 ICU stay (days)

100

120

Figure 2. The survival rates of the hypocapnia, normocapnia, and hypercapnia groups.

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value in the first 24 hours (the highest alveolar arterial gradient vs. the worst PaO2/FiO2 ratio), differences in diagnoses on admittance, differences in ICU management, and the fact that the latter study was conducted in 50 different centers and there may have been differences in practices in the ICUs. Other studies have shown that the majority of patients on mechanical ventilatory support in the ICUs are administered a large amount of oxygen and the ventilator settings are not adjusted according to hyperoxemic levels.[4,21] In a recent prospective, randomized, controlled study of critical patient groups on mechanical ventilatory support in ICU, Suzuki et al.[20] compared conventional and conservative oxygen treatment. They reported that restrictive oxygen therapy that aimed to keep the SpO2 value between 90% and 92% would not have any major clinical or physiological side effects. Although the mean PaO2 values of the conservative group were statistically lower than those of the conventional group (83 mmHg [71–97 mmHg] vs. 107 mmHg [94–131 mmHg]), no difference was determined in terms of mortality rates. However, Girardis et al.[19] reported lower mortality rates in the conservative group (mean PaO2: 87 mmHg [79–97 mmHg]) than the conventional group (mean PaO2: 102 mmHg [88–116 mmHg]) in a similar study. Comparing these studies with our study, the mean PaO2 values and mortality rates in our study were notably higher. This difference may be attributed to the detrimental effects of hyperoxia. In the current study, no statistically significant relationship was determined between mortality and the hypocapnia, normocapnia, and hypercapnia groups classified according to the arterial carbon dioxide values. A recent retrospective study of a large series of patients monitored in ICU with mechanical ventilation support demonstrated that hypocapnia led to poor clinical results.[22,23] A work by Del Castillo et al.[24] which examined the results of pediatric patients after cardiac arrest revealed that mortality has increased in hypocapnia and hypercapnia groups. In a meta-analysis of traumatic brain injury patients, Roberts et al.[25] reported that hypocapnia and hypercapnia were reasons for poor clinical outcomes. In our study, the reasons for the different results could have been that the patients were admitted to ICU for several reasons and the study methodology was different. Hence, there is a need for further studies of larger patient groups to investigate the relationship between partial carbon dioxide values and mortality. The most important limitation of this retrospective study was the difficulty in determining a causal relationship between oxygenation and in-hospital mortality. No clear statements have been made related to the limit values and standard categorization values, which are the most important determining factors in the relationship between arterial partial oxygen pressures and hypoxia, normoxia, and hyperoxia classifications. Hyperoxia has been described as PaO2 >300 mmHg and hypoxia as <60 mmHg[24,26,27] in some studies, but Brenner et al.[28] defined hyperoxia as PaO2 >200 mmHg and hypoxia as <60 mmHg. de Graaff et al.[4] and Eastwood et al.[18] also defined hyperoxia as 336

arterial oxygen pressure of >16 kPa or 120 mmHg. The international campaign for survival in sepsis and studies made on an ARDS study group recommended that in determining the clear arterial oxygen concentration values, the PaO2 value of arterial oxygen pressures in the least inspiratory oxygen fraction should be between 55 and 80 mmHg or the arterial hemoglobin saturation should be kept between 88% and 95%.[29] A similar definition was used in the current study and the hyperoxia group was defined to have pressure >120 mmHg. There are no standard categorizations related to oxygen values and no clear classification had affected the results of studies conducted. Our study was implemented in a single center with a limited number of patients. As previous similar studies have been made with larger patient series, it is difficult to determine the significant relationship between the two studies and to form an opinion of methods in the approach to hyperoxia in our country. Furthermore, the total hospital stay (days) and markers of clinical conditions of the patients were not available and the reasons for ventilator adjustment were unknown. As the study was planned according to the first blood gas values only, it was not possible to come to a conclusion on how long the values remained at normoxic and hyperoxic levels and how much this affected mortality. Although no significant relationship was determined between mortality and the oxygen values of the subgroups according to the diagnoses of the patients, further studies are warranted to examine subgroups of more extensive patient series.

Conclusion In conclusion, no significant relationship was determined between in-hospital mortality and the arterial oxygen pressure and arterial carbon dioxide pressure of patients on mechanical ventilation in ICU. In contrast to previous studies, the relationship between early hyperoxemia and mortality was unclear. As the current study was a retrospective, observational study, there is a need for further prospective, controlled research including national data collection with an organized recording system and interventional strategies to determine a causal relationship. Conflict of interest: None declared.

REFERENCES 1. Lindahl SG. Oxygen and life on earth: an anesthesiologist’s views on oxygen evolution, discovery, sensing, and utilization. Anesthesiology 2008;109:7−13. 2. Hafner S, Beloncle F, Koch A, Radermacher P, Asfar P. Hyperoxia in intensive care, emergency, and peri-operative medicine: Dr. Jekyll or Mr. Hyde? A 2015 update. Ann Intensive Care 2015;5:42. 3. Sinclair SE, Altemeier WA, Matute-Bello G, Chi EY. Augmented lung injury due to interaction between hyperoxia and mechanical ventilation. Crit Care Med 2004;32:2496−501. 4. de Graaff AE, Dongelmans DA, Binnekade JM, de Jonge E. Clinicians’ response to hyperoxia in ventilated patients in a Dutch ICU depends on the level of FiO2. Intensive Care Med 2011;37:46−51.

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Kaydu et al. Partial arterial oxygen pressure and mortality 5. Farquhar H, Weatherall M, Wijesinghe M, Perrin K, Ranchord A, Simmonds M, et al. Systematic review of studies of the effect of hyperoxia on coronary blood flow. Am Heart J 2009;158:371−7. 6. Bhandari V, Elias JA. Cytokines in tolerance to hyperoxia-induced injury in the developing and adult lung. Free Radic Biol Med 2006;41:4−18. 7. Branson RD, Robinson BR. Oxygen: when is more the enemy of good? Intensive Care Med 2011;37:1−3. 8. Balestra C, Germonpré P, Poortmans JR, Marroni A. Serum erythropoietin levels in healthy humans after a short period of normobaric and hyperbaric oxygen breathing: the “normobaric oxygen paradox”.J Appl Physiol (1985) 2006;100:512−8. 9. Calzia E, Asfar P, Hauser B, Matejovic M, Ballestra C, Radermacher P, et al. Hyperoxia may be beneficial. Crit Care Med 2010;38:S559−68. 10. Chura JC, Boyd A, Argenta PA. Surgical site infections and supplemental perioperative oxygen in colorectal surgery patients: a systematic review. Surg Infect (Larchmt) 2007;8:455−61. 11. Bitterman H. Bench-to-bedside review: oxygen as a drug. Crit Care 2009;13:205. 12. Kabon B, Kurz A. Optimal perioperative oxygen administration. Curr Opin Anaesthesiol 2006;19:11−8. 13. Singer M. Give oxygen, get a blood pressure... but don’t overdo it. Hosp Med 2005;66:73−5. 14. Eastwood GM, Reade MC, Peck L, Jones D, Bellomo R. Intensivists’ opinion and self-reported practice of oxygen therapy. Anaesth Intensive Care 2011;39:122−6. 15. Eastwood GM, O’Connell B, Considine J. Oxygen delivery to patients after cardiac surgery: a medical record audit. Crit Care Resusc 2009;11:238−43. 16. O’Driscoll BR, Howard LS, Davison AG; British Thoracic Society. BTS guideline for emergency oxygen use in adult patients. Thorax 2008;63:vi1−68. 17. de Jonge E, Peelen L, Keijzers PJ, Joore H, de Lange D, van der Voort PH, et al. Association between administered oxygen, arterial partial oxygen pressure and mortality in mechanically ventilated intensive care unit patients. Crit Care 2008;12:R156. 18. Eastwood G, Bellomo R, Bailey M, Taori G, Pilcher D, Young P, et al. Arterial oxygen tension and mortality in mechanically ventilated patients. Intensive Care Med 2012;38:91−8.

19. Girardis M, Busani S, Damiani E, Donati A, Rinaldi L, Marudi A, et al. Effect of Conservative vs Conventional Oxygen Therapy on Mortality Among Patients in an Intensive Care Unit: The Oxygen-ICU Randomized Clinical Trial. JAMA 2016;316:1583−9. 20. Suzuki S, Eastwood GM, Glassford NJ, Peck L, Young H, Garcia-Alvarez M, et al. Conservative oxygen therapy in mechanically ventilated patients: a pilot before-and-after trial. Crit Care Med 2014;42:1414−22. 21. Rachmale S, Li G, Wilson G, Malinchoc M, Gajic O. Practice of excessive F(IO(2)) and effect on pulmonary outcomes in mechanically ventilated patients with acute lung injury. Respir Care 2012;57:1887−93. 22. Schneider AG, Eastwood GM, Bellomo R, Bailey M, Lipcsey M, Pilcher D, et al. Arterial carbon dioxide tension and outcome in patients admitted to the intensive care unit after cardiac arrest. Resuscitation 2013;84:927−34. 23. Helmerhorst HJ, Schultz MJ, van der Voort PH, de Jonge E, van Westerloo DJ. Bench-to-bedside review: the effects of hyperoxia during critical illness. Crit Care 2015;19:284. 24. Del Castillo J, López-Herce J, Matamoros M, Cañadas S, Rodriguez-Calvo A, Cechetti C, et al. Hyperoxia, hypocapnia and hypercapnia as outcome factors after cardiac arrest in children. Resuscitation 2012;83:1456−61. 25. Roberts BW, Karagiannis P, Coletta M, Kilgannon JH, Chansky ME, Trzeciak S. Effects of PaCO2 derangements on clinical outcomes after cerebral injury: A systematic review. Resuscitation 2015;91:32−41. 26. Douzinas EE, Patsouris E, Kypriades EM, Makris DJ, Andrianakis I, Korkolopoulou P, et al. Hypoxaemic reperfusion ameliorates the histopathological changes in the pig brain after a severe global cerebral ischaemic insult. Intensive Care Med 2001;27:905−10. 27. Kilgannon JH, Jones AE, Shapiro NI, Angelos MG, Milcarek B, Hunter K, et al. Association between arterial hyperoxia following resuscitation from cardiac arrest and in-hospital mortality. JAMA 2010;303:2165−71. 28. Brenner M, Stein D, Hu P, Kufera J, Wooford M, Scalea T. Association between early hyperoxia and worse outcomes after traumatic brain injury. Arch Surg 2012;147:1042−6. 29. Young P, Beasley R, Bailey M, Bellomo R, Eastwood GM, Nichol A, et al. The association between early arterial oxygenation and mortality in ventilated patients with acute ischaemic stroke. Crit Care Resusc 2012;14:14−9.

DENEYSEL ÇALIŞMA - ÖZET OLGU SUNUMU

Yoğun bakım ünitesinde mekanik ventilatör desteği ile takip edilen hastalarda arteriyel oksijen basıncı ile mortalite arasındaki ilişki Dr. Ayhan Kaydu,1 Dr. Günseli Orhun,2 Dr. Nahit Çakar3 1 2 3

Diyarbakır Selahaddin Eyyubi Devlet Hastanesi, Anesteziyoloji ve Reanimasyon Kliniği, Diyarbakır İstanbul Üniversitesi Tıp Fakültesi, Anesteziyoloji ve Reanimasyon Anabilim Dalı, İstanbul Koç Üniversitesi Tıp Fakültesi, Anesteziyoloji ve Reanimasyon Anabilim Dalı, İstanbul

AMAÇ: Hiperoksinin yoğun bakım ünitelerinde mekanik ventilasyon desteği ile takip edilen hastalarda mortalite ve morbiditeyi artıran bağımsız bir risk faktörü olduğuna dair farklı çalışmalar olmasına rağmen bu konu belirsizliğini korumaktadır. GEREÇ VE YÖNTEM: Bu çalışma, etik komite onayı alındıktan sonra mekanik ventilatör desteği ile yoğun bakım ünitesine takip edilen 18 yaş üzerindeki 7689 hastanın ilk 24 saatteki verileri incelenerek yapılan geriye dönük, gözlemsel bir çalışmadır. Hastaların demografik özellikleri, mekanik ventilasyon ve kan gazı parametleri analiz edildi. Hiperoksemiyi PaO2 ≥120 mmHg, normoksemiyi PaO2 60–120 mmHg olarak tanımlandı. PaCO2 değeri <30 mmHg olan hastalar hipokapnik, 30–50 mmHg olanlar normokapnik, >50 mmHg olanlar hiperkapnik olarak tanımlandı. BULGULAR: Hastaların yaş ortalaması 59.60±16.96 (dağılım, 18–93) yıl idi. Ortalama PaO2 değeri 16.2 kPa (121.50 mmHg) ve FiO2 değeri %60 idi. İki yüz otuz iki hasta normoksi (%51.5) ve 218 hastada (%48.5) hiperoksi gözlendi. Hastaların mortalite oran %56 idi. PaO2 düzeyleri ve PCO2 düzeyleri ile mortalite arasında istatistiksel olarak anlamlı fark bulunmadı (p>0.05). PaO2 ve FiO2 sınıflamasına göre mortalitede istatistiksel olarak anlamlı fark yoktu (p>0.05). PCO2 sınıflamasına göre sağkalım oranları arasında istatistiksel olarak anlamlı fark bulunmadı (p=0.602, p>0.05). TARTIŞMA: Yoğun bakım ünitesindeki mekanik ventilatör desteği ile takip edilen hastalarda oksijen ve karbondioksit değerleri ile mortalite arasında anlamlı ilişki bulunmadı. Anahtar sözcükler: Hiperoksemi; mekanik ventilasyon; normoksemi; oksijen toksisitesi; yoğun bakım ünitesi. Ulus Travma Acil Cerrahi Derg 2019;25(4):331-337

doi: 10.5505/tjtes.2018.51430

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EXPERIMENTAL STUDY

Comparison of Ankaferd Blood Stopper and silver sulfadiazine use in burn wounds: An experimental study Serden Ay, M.D.,1

Yaşar Ünlü, M.D.2

1

Department of General Surgery, KTO Karatay University Faculty of Medicine, Konya-Turkey

2

Department of Pathology, Health Sciences University Konya Training and Research Hospital, Konya-Turkey

ABSTRACT BACKGROUND: The present study was designed to compare the effectiveness of topical silver sulfadiazine (SSD) and Ankaferd Blood Stopper® (ABS) usage in experimental partial-thickness burns in rats. METHODS: Twenty-one male Wistar albino rats weighing 250–290 (range: 270±19) g were used in the present study. A round brass probe that was specifically designed (3×3 cm diameter) was used to induce the burns in rats. After the presence of partial-thickness burns was confirmed, the rats were divided into three groups: Group 1 (ABS group) Ankaferd Blood Stopper® pad, Group 2 (SSD group) silver sulfadiazine (Silverdin®), and Group 3 (Control group) 1% isotonic saline solution-impregnated pad. The healing period was followed up clinically and histopathologically. The day on which 50% and 80% of re-epithelization at first were detected for each rat was also recorded. RESULTS: The mean times of 50% and 80% of re-epithelization at first were 10.8 days, 13.8 days, and 16.8 days in Groups 1, 2, and 3, respectively (p<0.001), and 16.4 days, 19.7 days, and 25.2 days, respectively (p<0.001). The mean inflammatory scores were also found to be better in the ABS group than in other groups (p<0.05). CONCLUSION: Our study showed that ABS has better results for the healing of the burn wound than SSD in experimental partialthickness burns in rats. Keywords: Ankaferd Blood Stopper; burn; experimental study; silver sulfadiazine.

INTRODUCTION Burn injuries, an important global public health issue, are still considered to be among the most destructive of all types of injuries. The main goal of the treatment of burns is a fast epithelization and wound healing to prevent secondary infections, as well as to reduce the functional and aesthetic issues. On the other hand, the likelihood of occurrence of deformities, mis-formation, and infection at the burn site of the wound are the main concerns toward their implementation.[1] Topical agents may decrease the morbidity and mortality rates by preventing sepsis and bacterial contamination during the healing process of the burn wounds. Currently, in severe burns, silver sulfadiazine (SSD) as a topical agent is used

worldwide.[2] In addition to its effectiveness, SSD cream has some important systemic complications, such as neutropenia, erythema multiforme, methemoglobinemia, and crystalluria.[3] Ankaferd Blood Stopper (ABS) (İmmun İlaç Kozmetik Ltd., Istanbul, Turkey) is a traditional and unique medicinal plant extract that has historically been used in Turkey as a hemostatic agent.[4] The promising result of ABS in promoting tissue healing has been shown in several studies recently.[5] Thus, the aim of the experimental study was to compare the effectiveness of topical ABS and SSD in partial-thickness burns in rats.

MATERIALS AND METHODS After obtaining permission from the ethical board of our uni-

Cite this article as: Ay S, Ünlü Y. Comparison of Ankaferd Blood Stopper and silver sulfadiazine use in burn wounds: An experimental study. Ulus Travma Acil Cerrahi Derg 2019;25:338-342. Address for correspondence: Serden Ay, M.D. Hacı Şaban Mah., Meram Yeniyol Cad., No: 97, 42040 Meram, Konya, Turkey Tel: +90 332 - 323 67 09 E-mail: serdenay@yahoo.com Ulus Travma Acil Cerrahi Derg 2019;25(4):338-342 DOI: 10.14744/tjtes.2019.38265 Submitted: 19.11.2018 Accepted: 24.05.2019 Online: 08.07.2019 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

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Anesthesia was administered by a single dose of 50 mg/kg ketamine hydrochloride (Ketalar 50 mg/mL; Parke-Davis, MI, USA) and 6 mg/kg intramuscular xylazine hydrochloride (Rompun 23.32 mg/mL; Bayer, Leverkusen, Germany). The back region of the rats was shaved and cleaned with a 10% povidone–iodine solution (Kim-Pa, Poviiodeks, 10% povidone–iodine). A specifically designed round brass probe (3×3 cm diameter) was used to induce the burns (Fig. 1). After sterilization in boiling water for 5 min, the probe was applied with no pressure to the skin of anesthetized rats for 15 s. With this procedure, second-degree partial-thickness burns were formed. After the burns were formed, all the rats were placed and kept in individual cages and divided into three groups. Ankaferd Blood Stopper® pad was used in Group 1 (ABS group), silver sulfadiazine (Silverdin®; Toprak Drug Co., Turkey) 1% in Group 2 (SSD group), and isotonic saline solution-impregnated pads in Group 3 (Control group). The healing period was observed clinically and histopathologically. To specify the wound healing process, two parameters were used as follows: 1. the exact day on which 50% and 80% of re-epithelization were detected at first 2. histopathological changes.

a camera every day 3 of the follow-up. On week 4 of the follow-up period, for histological evaluation, skin samples were obtained at the same distance and under the same conditions. The healing process of the burns was evaluated by the same clinician who is experienced on burn and blinded to the study. The measurements of the burn areas were evaluated using the NIH ImageJ program as described in our previous study.[6] The percentage of re-epithelization was calculated as follows: Percentage of re-epithelization=first burn area–current burn area/first burn area. The 50% and 80% of re-epithelization rates were recorded precisely until the end of the study. All the rats were sacrificed after the photos were taken on week 4 of the study. The resected full-thickness skin samples were collected from the burn areas. Histological parameters (epithelialization, polymorphonuclear neutrophil (PMN), angiogenesis, and fibrosis) were evaluated on biopsy specimens of the wounds at the end of the study as follows: for fibrosis (collagen bundles): normal bundle: 2, disorganized/edematous: 1, and amorphous: 0 and for PMN: 40× field: 0–10: 2, 11–40: 1, and >40: 0. 20

15

Days

versity, the study was designed according to the Health Guide for the Care and Use of Laboratory Animals by the National Institutes of Health (NIH publication no.: 86–23, revised 1985, Bethesda) criteria. The study was completed at the Experimental Research Center of Necmettin Erbakan University. A total of 21 male Wistar albino rats weighing 250–290 (range: 270±19) g were used for the study. The rats were kept at an equal hour light and dark cycle at a temperature of 22 °C–26 °C. They were given a standard rat diet. By means of drinking water, 100 mg/5 mL ibuprofen was administered as an analgesic after the burn formation. The rats were set up individually and approached with appropriate equipment to prevent contamination.

10

5

0

Ankaferd Blood Stopper®

Silver sulfadiazine

Control

Reepitelization 50%

Figure 2. Times to 50% of re-epithelization.

The study period did not end until 4 weeks after the burns were observed. Digital photos of the burns were taken with

30 25

Days

20 15 10 5 0

Figure 1. The application of brass and burn formation.

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Ankaferd Blood Stopper®

Silver sulfadiazine

Control

Reepitelization 80%

Figure 3. Times to 80% of re-epithelization.

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Table 1. Inflamation and collagen scores of the groups Characteristic

Group Group Control p ABS SSD group

Inflammation scores 1.71±0.48 0.85±0.37 0.28±0.48 <0.001 Collagen bundles

1.85±0.37 1.28±0.48 0.42±0.53 <0.001

ABS: Ankaferd Blood Stopper®; SSD: Silver sulfadiazine.

Data were analyzed by using Statistical Package for the Social Sciences (SPSS) 19.0 for Windows program (SPSS Inc., Chicago, IL, USA). One-way ANOVA and Tukey’s post hoc test were used to analyze the data. A p value <0.05 was considered as statistically significant.

RESULTS The mean times for 50% of re-epithelization at first were 10.8 days, 13.8 days, and 16.8 days in the ABS group, SSD group, and control group, respectively (p<0.001) (Fig. 2), and

for 80% of re-epithelization at first were 16.4 days, 19.7 days, and 25.2 days, respectively (p<0.001) (Fig. 3). The ABS group had faster healing duration than the other groups with respect to 50% and 80% of re-epithelization (Fig. 4). These differences were statistically significant. The SSD group had also better healing rates than the control group based on 50% and 80% of re-epithelization of the burn. The mean inflammatory scores revealed a significant difference in the ABS group compared with the others (p<0.05). The collagen scores were also higher in the ABS group than in the other groups (Table 1) (p<0.05) (Fig. 5a-c).

DISCUSSION The overall process of burn healing is similar with that seen in the wound healing process which generally follows the phases of inflammation, proliferation, and remodeling. This healing process can be obstructed due to many reasons. Miscellaneous studies have shown that infection not only is the main cause for the failure of healing but also can increase the risk of mortality among burn patients.[7] Thus far, many investiga-

Figure 4. Burn wounds on days 3, 9, 15, and 21.

(a)

(b)

(c)

Figure 5. (a) Beneath the preserved epidermis, within the dermis infiltrated with mild fibrosis and inflammation, adnexas can be chosen (ABS group). (b) Beneath the preserved epidermis, within the dermis infiltrated with partial fibrosis and inflammation, adnexas cannot be observed (SSD group). (c) At the end of 4 weeks, beneath the epidermis, which is not well-preserved, obvious fibrosis and inflammation can be observed, and adnexas are not visible (Control group).

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tions have been conducted to understand how to prevent secondary infection and to accelerate the healing process. Usage of topical antibiotics has already been determined as effective in preventing mortality.[8] SSD, one of the popular topical antibiotics, is convenient widely and easy to use, gives no pain, and has low toxicity while showing a good antibacterial effect. Therefore, SSD is the gold standard as an antimicrobial topical ointment in burn patients now.[9] In addition to its antimicrobial effect, SSD has a positive effect on the proliferation of fibroblasts producing collagen and fibronectin and stimulates the production of growth factor and cytokines from cells, such as macrophages during the wound healing process.[10] However, there are some side effects of SSD, such as neutropenia, erythema multiforme, crystalluria, and methemoglobinemia, and can delay the wound healing process.[3] On the other hand, the healing of the burn wound is still controversial. There are only a few drugs ruling the physiological wound healing defined to be effective.[11] In the past few years, the effect of some herbal medicine on burn wounds has been investigated widely, and several products derived from plants have been shown to have strong wound healing effects.[11] While most of the medicines are a mixture of several plants, none of these traditional ointments were studied prominently. In the present study, ABS was compared with SSD as a standard treatment for burns in rats. ABS, a unique traditional herbal medicine that has been consumed for many years in Anatolia as a hemostatic agent, was certified by the Turkish Ministry of Health in October 2007. [12] ABS is a standardized mixture of the plants Alpinia officinarum, Thymus vulgaris, Vitis vinifera, Urtica dioica, and Glycyrrhiza glabra. Each of these plants ABS consumes has some various beneficial effect on blood cells, endothelium, cellular proliferation, angiogenesis, cell mediators, and/or vascular dynamics.[13] In addition to its hemostatic activity, ABS may also prevent bacterial growth.[14] In a previous study, the antimicrobial activity of ABS was tested against 102 clinical isolates, which reported that ABS was active against all of these isolates, and the zones of inhibition were within a range of 8–10 mm diameter.[15] The antibacterial efficiency of ABS toward Gram-negative and Gram-positive food, as well as human pathogens, has also been determined.[14] Neither systemic nor local adverse effects and/or toxicity have been seen in association with anecdotal and experimental topical uses of ABS. Hematotoxicity, acute mucosal toxicity, nephrotoxicity, hepatotoxicity, and biochemical toxicity have not also been defined during the short-term follow-up of animals.[14] The comparison between the groups in our study showed that ABS was statistically significantly superior with respect to histopathological evaluation and recovery duration compared with the previously proven SSD. Kaya et al.[16] and Topal et al.[17] have previously demonstrated that even though the ABS and control groups are similar with respect to wound healing on day 7, ABS is statistically superior on day 14. In Ulus Travma Acil Cerrahi Derg, July 2019, Vol. 25, No. 4

contrast, Topal et al.[17] could not determine any difference between ABS and SSD in burn wounds. On the other hand, in our study, ABS had a shorter recovery time than SSD based on 50% and 80% of re-epithelization rates. In our opinion, ABS may have a superior beneficial effect and can be widely used in the treatments of burn injuries, instead of SSD usage. Conflict of interest: None declared.

REFERENCES 1. Rowan MP, Cancio LC, Elster EA, Burmeister DM, Rose LF, Natesan S, et al. Burn wound healing and treatment: review and advancements. Crit Care 2015;19:243. 2. Papini RP, Wilson AP, Steer JA, McGrouther DA, Parkhouse N. Wound management in burn centres in the United Kingdom. Br J Surg 1995;82:505–9. 3. Atiyeh BS, Costagliola M, Hayek SN, Dibo SA. Effect of silver on burn wound infection control and healing: review of the literature. Burns 2007;33:139–48. 4. Goker H, Haznedaroglu IC, Ercetin S, Kirazli S, Akman U, Ozturk Y, et al. Haemostatic actions of the folkloric medicinal plant extract Ankaferd Blood Stopper. J Int Med Res 2008;36:163–70. 5. Akalin C, Kuru S, Barlas AM, Kismet K, Kaptanoglu B, Demir A, et al. Beneficial effects of Ankaferd Blood Stopper on dermal wound healing: an experimental study. Int Wound J 2014;11:64–8. 6. Arslan K, Karahan O, Okuş A, Unlü Y, Eryılmaz MA, Ay S, et al. Comparison of topical zinc oxide and silver sulfadiazine in burn wounds: an experimental study. Ulus Travma Acil Cerrahi Derg 2012;18:376–83. 7. Velnar T, Bailey T, Smrkolj V. The wound healing process: an overview of the cellular and molecular mechanisms. J Int Med Res 2009;37:1528–42. 8. D’Avignon LC, Saffle JR, Chung KK, Cancio LC. Prevention and management of infections associated with burns in the combat casualty. J Trauma 2008;64:S277–86. 9. Kimura Y, Sumiyoshi M, Kawahira K, Sakanaka M. Effects of ginseng saponins isolated from Red Ginseng roots on burn wound healing in mice. Br J Pharmacol 2006;148:860–70. 10. Nascimento EG, Sampaio TB, Medeiros AC, Azevedo EP. Evaluation of chitosan gel with 1% silver sulfadiazine as an alternative for burn wound treatment in rats. Acta Cir Bras 2009;24:460–5. 11. Akhoondinasab MR, Akhoondinasab M, Saberi M. Comparison of healing effect of aloe vera extract and silver sulfadiazine in burn injuries in experimental rat model. World J Plast Surg 2014;3:29–34. 12. Kandemir O, Buyukates M, Kandemir NO, Aktunc E, Gul AE, Gul S, et al. Demonstration of the histopathological and immunohistochemical effects of a novel hemostatic agent, Ankaferd Blood Stopper, on vascular tissue in a rat aortic bleeding model. J Cardiothorac Surg 2010;5:110. 13. Beyazit Y, Kekilli M, Haznedaroglu IC, Kayacetin E, Basaranoglu M. Ankaferd hemostat in the management of gastrointestinal hemorrhages. World J Gastroenterol 2011;17:3962–70. 14. Bilgili H, Captug O, Kosar A, Kurt M, Kekilli M, Shorbagi A, et al. Oral systemic administration of Ankaferd blood stopper has no short-term toxicity in an in vivo rabbit experimental model. Clin Appl Thromb Hemost 2010;16:533–6. 15. Tasdelen Fisgin N, Tanriverdi Cayci Y, Coban AY, Ozatli D, Tanyel E, Durupinar B, et al. Antimicrobial activity of plant extract Ankaferd Blood Stopper. Fitoterapia 2009;80:48–50. 16. Kaya H, Gokdemir M, Sogut O, Demir T, Kocarslan S. Effects of Folk Medicinal Plant Extract Ankaferd Blood Stopper On Burn Wound Healing. Acta Medica Mediterranea 2013:29;497–502. 17. Topal A, Gul Satar NY, Cangul T, Ayberk Oktay M, Inan K, Cecen G, et al. Ankaferd blood stopper accelerates deep second degree burn wound healing in rats. Acta Veterinaria Brno 87:261–7.

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DENEYSEL ÇALIŞMA - ÖZET OLGU SUNUMU

Yanık yarası tedavisinde Ankaferd Blood Stoper ile gümüş sülfadiazinin karşılaştırılması: Deneysel çalışma Dr. Serden Ay,1 Dr. Yaşar Ünlü2 1 2

KTO Karatay Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Konya Sağlık Bilimler Üniversitesi, Konya Eğitim ve Araştırma Hastanesi, Patoloji Kliniği, Konya

AMAÇ: Bu deneysel çalışma yanık yaralarında Ankaferd Blood Stoper ve gümüş sülfadiazinin (SSD) etkinliğini karşılaştırmak üzere dizayn edilmiştir. GEREÇ VE YÖNTEM: Çalışma için Wistar albino cinsi 21 sıçan kullanıldı. Yanık oluşturmak için 3x3 cm çapında yuvarlak özel dizayn edilmiş pirinç prob kullanıldı. Yanık oluşturulduktan sonra, sıçanlar üç gruba ayrıldı. Ankaferd Blood Stoper (Grup ABS) grup 1’de, Gümüş sülfadiazin (Grup SSD) grup 2’de, izotonik emdirilmiş spançlarda (Grup kontrol) grup 3’de kullanıldı. İyilişme dönemi klinik ve histoplatolojik olarak takip edildi. Yara ölçümleri yapıldı, %50 ve %80 re-epitelizasyona ulaştığı günler her sıçan için belirlendi. BULGULAR: Ortalama %50 re-epitelizasyon zamanı sırasıyla ABS grubu için 10.8 gün, SSD grubu için 13.8 gün ve kontrol grubu için 16.8 gündü (p<0.001). Yine ortalama %80 re-epitelizasyon zamanı sırasıyla ABS grubu için 16.4 gün, SSD grubu için 19.7 gün ve kontrol grubu için 25.2 gündü (p<0.001). Ortalama enflamatuvar skora göre, ABS grubunda anlamlı bir fark mevcuttu (p<0.05). TARTIŞMA: Çalışmamız ABS’nin yanık tedavisinde, SSD’ye oranla daha iyi sonuçları olduğunu göstermiştir. Anahtar sözcükler: Ankaferd Blood Stoper; deneysel çalışma; gümüş sülfadiazin; yanık. Ulus Travma Acil Cerrahi Derg 2019;25(4):338-342

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doi: 10.14744/tjtes.2019.38265

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k

EXPERIMENTAL STUDY

Assessing the therapeutic effect of resveratrol in heart failure following blunt chest trauma and the potential role of endocan as a biomarker of inflammation using rats Aysun Çağlar Torun, M.D.,1

Şerife Tütüncü, M.D.2

1

Department of Oral and Maxillofacial Surgery, Ondokuz Mayis University Faculty of Dentistry, Samsun-Turkey

2

Department of Histology and Embryology, Ondokuz Mayis University Faculty of Veterinary, Samsun-Turkey

ABSTRACT BACKGROUND: The present study investigated the therapeutic effect of resveratrol on cardiac injury resulting from blunt chest trauma and the utility of endocan as a biomarker of the inflammation process using rats. METHODS: The rats were randomly divided into the following four groups (n=7 in each group): a control group (no treatment or trauma); trauma-induced group (trauma group); resveratrol group (resveratrol 0.3 mg/kg administered via the intraperitoneal [i.p.] route group); and resveratrol + trauma group (resveratrol 0.3 mg/kg administered via the i.p. route 1 hour prior to the induction of trauma). RESULTS: The immunoreactivity of tumor necrosis factor-α and inducible nitric oxide synthase in the trauma group was increased, whereas the reaction intensity in resveratrol + trauma group was deceased. The mean endocan values of the differed between the groups (p<0.001). The mean endocan value in the resveratrol + trauma group was higher than that of the other groups. CONCLUSION: Resveratrol exhibited anti-inflammatory and antioxidant effects in lung injury after blunt chest trauma and contributed favorably to the treatment process. We believe that there is a need for further studies on the clinical use of endocan as a biomarker of inflammation in cardiac injury after blunt chest trauma. Keywords: Blunt chest trauma; cardiac injury; endocan; resveratrol.

INTRODUCTION Nutraceuticals are derived from foods and have pharmacological and therapeutic properties.[1] Resveratrol is a natural phenolic compound that has many beneficial effects on the human body. It is present in abundant amounts in grapes, peanuts, strawberries, and plums. Previous studies investigated the effects of resveratrol in various diseases.[2–4] One study reported that resveratrol exhibited antiatherogenic properties by decreasing the levels of prostaglandin E2 and plasminogen activator inhibitor-1.[3] Another study showed that resveratrol had anticancer properties, increasing vascular endothelial growth factor and levels of apoptosis regulator Bax.[5] Further research suggested that resveratrol regulated metabolism, glucose, and lipid levels and that it had positive effects on

chronic diseases, such as diabetes, obesity, and liver disease.[6] Studies have also examined the effects of resveratrol on cardiovascular diseases, especially atherosclerotic heart diseases and hypertension.[7,8] It was found that resveratrol protected cardiomyocytes from oxidative stress, limited inflammation associated with atherosclerosis by reducing prostaglandin E2 levels, and exhibited anti-inflammatory properties.[9] Further, it exerted a positive effect on hypertension by inducing vasodilatation and neovascularization.[5] However, there have been no studies till date that assess the effect of resveratrol on cardiac contusions caused by blunt chest trauma. Blunt chest trauma can cause fatal complications, as it affects the organs that regulate vital functions, such as the heart and lungs. Rapid detection and treatment of the damage can be

Cite this article as: Torun AÇ, Tütüncü Ş. Assessing the therapeutic effect of resveratrol in heart failure following blunt chest trauma and the potential role of endocan as a biomarker of inflammation using rats. Ulus Travma Acil Cerrahi Derg 2019;25:343-349. Address for correspondence: Aysun Çağlar Torun, M.D. Ondokuz Mayıs Universitesi Diş Hekimliği Fakültesi, 55139 Samsun, Turkey Tel: +90 362 - 312 19 19 E-mail: aysunct@hotmail.com Ulus Travma Acil Cerrahi Derg 2019;25(4):343-349 DOI: 10.5505/tjtes.2018.77246 Submitted: 01.03.2018 Accepted: 22.10.2018 Online: 09.07.2019 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

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life-saving.[10,11] However, blunt chest trauma can be difficult to detect due to inadequate diagnostic methods and lack of a gold standard. The mortality rate after blunt chest trauma increases in the presence of heart failure.[12] For this reason, new methods and markers are needed for rapid diagnosis. The endothelium is the largest organ in the body and plays a role in many pathological conditions in the vasculature. The main function of the endothelium is to provide an anticlotting surface and induce the release of vasoactive substances and various cytokines that facilitate the inflammatory process. Endocan, a protein synthesized from active vascular endothelial cells, exhibits anti-inflammatory properties by inhibiting leukocyte adhesion and migration.[13] Some previous studies found that high endocan levels were associated with various medical conditions, such as inflammation, cancer, sepsis, and obesity.[13–15] There are different results, even in limited numbers of sample groups.[16,17] The present study used rats to investigate the therapeutic effect of resveratrol on cardiac injury resulting from blunt chest trauma, the association of serum levels of endocan with the inflammation process, and the utility of endocan as a biomarker of inflammation in cardiac disease.

placed on the chest, without intervention by the neck or abdomen (Fig. 1).[18] The anesthetized rats were fixed between the lower and upper platform, with their chests facing upward. Thoracic trauma was induced by placing a hollow aluminum cylinder weight (0.3 kg) through a vertical stainless steel tube on the Lexan platform adjacent to the chest. After 24 hours, all the experimental rats were sacrificed with an i.p. injection of ketamine hydrochloride. Approximately 3 ml of blood samples were collected in tubes with cardiac puncture anticoagulant for biochemical analyses. The tubes containing the blood were left in the room for 30 minutes to clot. The sera were then centrifuged at 3000 g for 10 minutes at 4°C and were stored at −80°C until used in the analysis. After the surgical procedure, heart samples were collected for histopathological and immunohistochemical investigations.

Histopathological Studies Materials were prepared by appropriate methods and then preserved in 10% formaldehyde solution for histological

MATERIALS AND METHODS

Hollow Weight Pin

The experimental protocol and all animal procedures were approved by the Experimental Ethics Committee.

Animals and Experimental Protocol All animals were provided by the Experimental Research Center. A total of 28 female Sprague-Dawley rats weighing 235–275 g were used in the experiments. They were kept under standard experimental laboratory conditions (temperature: 24°C; dark/light cycle: 12/12 hours; free access to food and water; relative humidity: 60%). The rats were anesthetized with an intraperitoneal (i.p.) injection of ketamine hydrochloride (100 mg/kg) and xylazine (10 mg/kg) and allowed to breathe spontaneously during the procedure. The rats were randomly divided into four groups (n = 7 in each): a control group, trauma group (trauma only), resveratrol group (resveratrol treatment administered via the i.p. route), and resveratrol + trauma group (resveratrol treatment administered 1 hour prior to trauma). The resveratrol (Sigma Aldrich, Germany) dose was 0.3 mg/kg i.p.[4] Trauma model: A platform was suspended on Teflon rails to reduce friction and facilitate energy transfer to the animal. An important feature of the model, a precordial protective shield (Plexiglas), was placed under the Lexon Platome in direct contact with the chest. This shield directs the energy of the pulse toward the side of the chest. The xiphoid field was clearly marked on each animal, and the shield was repeatedly 344

Steel Tube

Teflon Lined Groove

Lexon Platform Plastic Shield Animal

Plexiglass Base Schematic Representation of the Model Figure 1. Schematic of the rat model of isolated bilateral pulmonary contusion. A hollow cylindrical weight held in place with a pin at a defined height was dropped through a steel tube onto a Lexon platform with an underlying precordial shield contacting the chest of an anesthetized rat. Teflon guides minimize fractional dissipation and maximize energy transfer to the animal. The precordial shield allowed the induction of bilateral pulmonary contusion but spared the mediastinum and associated structures. The severity of lung contusion was dependent on the impact force of the falling weight in Joules.

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examinations. Subsequently, the materials were routinely subjected to histological tissue sequencing procedures and blocked in paraffin. After cutting sections of 5 μm thickness from paraffin blocks, Crossman’s triple staining method was used to examine the histological structures. The resulting preparations were photographed under a Nikon E600 research microscope containing a Nikon digital-sight imaging system.[19]

Immunohistochemistry Procedure In the 5 μm lung sections cut from paraffin blocks, the presence of tumor necrosis factor-α (TNF-α) and inducible nitric oxide synthase (iNOS) was examined by immunohistochemical methods using the streptavidin-biotin complex method. [20] In immunohistochemical staining, rabbit polyclonal TNF-α (Abcam, ab9739) and rabbit polyclonal iNOS (Abcam, ab3523) primary antibodies were used. The Histostain Plus rabbit primary (Zymed kit: 85-6743) kit was used as the secondary antibody. The sections were deparaffinized and then heated in a 700 watt microwave oven for proteolysis in a citrate buffer (pH: 6) solution. The tissues were then incubated in 3% hydrogen peroxide solution to prevent endogenous peroxidase activity. After washing with phosphate buffered saline (PBS), serum was instilled into the kit to prevent nonspecific protein binding in the sections. Primary antibodies with 1/200 (TNF-α) and 1/250 (iNOS) dilutions were then instilled into the sections and incubated at − 4°C overnight. Only PBS solution was instilled into the negative control group tissues. Following washing, the biotinylated secondary antibody was added to the sections and incubated with the streptavidin-HRP complex. In the last step, 3,3’-diaminobenzidine was used as a chromogen and the preparations were sealed with adhesive and counterstained with hematoxylin. In the immunohistochemical evaluations, values of 0 to 3 were assigned according to the level of staining: unstained (-), weak staining (+), moderate staining (++), and severe staining (+++).

Biochemical Procedure All the samples were allowed to dissolve at 2°C–8°C the day before the analyses were performed. Serum samples of endocan were measured using a rat ESM-1 ELISA kit (Bioassay Technology Laboratory, Shanghai, China) in accordance with the manufacturer’s protocol. Troponin I (TnI) was determined using a Rat TnI ELISA kit (E Lab science, Texas, U.S.A.), and N- terminal pro-brain natriuretic peptide (NT pro-BNP) was

(a)

(b)

determined using a Rat NT pro-BNP ELISA kit (E Lab science, Texas, U.S.A.) in accordance with the procedures specified by the manufacturer. TnI, NT pro-BNP, and endocan levels are given in ng/ml.

Statistical Analysis Data were analyzed using the SPSS 21.0 package software. The measurements obtained were expressed in median (minimum-maximum). For data with a normal distribution, an analysis of variance was performed. The Kruskal–Wallis test was conducted for data showing a non- normal distribution. The level of statistical significance was accepted at p<0.05.

RESULTS Histopathological Results The histopathological analysis revealed three main layers (endocardium, myocardium, and pericardium) in the heart tissue. Endocardium, a thin membrane covering the inside of the atrium and ventricles, was present at the innermost layer of the tissue. The middle layer was fairly thick and consisted of heart cells. On the outermost side, a thin membrane epicardium consisting of the visceral leaf of the pericardium was observed. Intercalated disc spaces and collateral connections between the cardiac cells were clearly visible. Degeneration, necrosis, and hemorrhage foci of the myocardium were as follows: Control group: In general, there were no anomalies in the heart muscle cells and few degenerative and necrotic cells were identified. Pyknosis of cell nuclei was observed in addition to acidophilic staining of cytoplasmic proteins (Fig. 2a). Trauma group: Foci of degeneration and necrosis were observed in addition to increased hemorrhages in myocytes as compared to the control group (Fig. 2b). Resveratrol group: As compared to the control group, there were no significant differences in the tissue (Fig. 2c). Resveratrol + trauma group: As compared to the control group, degeneration, pyknosis, and necrosis were present. In the histopathological examination, there were no significant differences between this group and the trauma group (Fig. 2d)

(c)

(d)

Figure 2. (a) Control group, (b) trauma group, (c) resveratrol group, (d) resveratrol + trauma (Crossman, trichrome dyeing); asterisk: normal heartbeat, thick arrow: necrotic heartbeat cells, thin arrow: degenerative heartbeat cells, x20.

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Table 1. Mean immunohistochemical reaction intensities of iNOS ve TNF-α

Control group

Trauma group

Resveratrol group

Resveratrol + trauma group

++

+++

+

++

Inducible nitric oxide synthase

Tumor necrosis factor-α + ++ +

+

No staining (-), poor staining (+), moderate staining (++) and severe staining (+++).

Table 2. Serum TnI, NT pro-BNP, and endocan levels according to groups

Troponin I (ng/mL)

NT pro-BNP (ng/mL)

Endocan (ng/mL)

Control group

234.3±26.6

595.8±74.7

207.9±61a

Trauma group

206.5±20.7

632.8±111

408.8±39.8b

213.9±23

593.7±92.9

472.6±50.2b

222.1±43.4

481±224.9

710.5±214.3c

Resveratrol group Resveratrol + travma group p

0.361 0.223 <0.001

Values are expressed as means±standard deviation, n=7 for each group. TnI: Troponin I; NT pro-BNP: N- terminal pro-brain natriuretic peptide.

Immunohistochemical Results Analysis of the tissue preparations of each of the groups revealed immunoreactivity of antibodies in heart muscle cells and intracytoplasmic staining. iNOS: In the between-group comparison, the intensity of staining/immunoreaction in the control group and resveratrol + trauma group was similar (medium intensity). The intensity of staining/immunoreaction was weak in the resveratrol group as compared to other groups. The most severe reaction was detected in the trauma group (Table 1, Fig. 3). TNF-α: Severity of staining/immunoreaction (moderate) in

(a)

(b)

the trauma group was more pronounced than that in the other groups. The reaction intensities in the other three groups were similar to each other (weak) (Table 1, Fig. 4).

Biochemical Results The serum values of TnI, NT pro-BNP, and endocan, in addition to statistical differences in these measurements, are shown in Table 2. The values of TnI did not differ between the groups (p=0.361). Similarly, there was no between-group difference in NT pro-BNP values (p=0.223). However, the mean values of endocan differed between the groups (p<0.001). The lowest mean value was obtained in the control group. There was no difference in endocan values between the

(c)

(d)

Figure 3. (a) Control group, (b) trauma group, (c) resveratrol group, (d) resveratrol + trauma group (iNOS), arrow: immunopositive cardiomyocytes, x20.

(a)

(b)

(c)

(d)

Figure 4. (a) Control group, (b) trauma group, (c) Resveratrol group, (d) Resveratrol + trauma group (TNF α), arrow: immunopositive cardiomyocytes, x20.

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trauma and resveratrol groups. The mean endocan value in the resveratrol + trauma group was higher than that of all the other groups.

DISCUSSION The effects of resveratrol on many cardiac diseases have been investigated in clinical and experimental studies.[1,2] One study reported the positive effects of resveratrol on ischemiareperfusion injury and myocardial ischemia.[21] Zheng et al.[21] reported that resveratrol attenuated hypoxia-reperfusion injury induced in rats and that resveratrol had antiaging properties. Similarly, Hashemzaei et al.[22] found that resveratrol reduced cardiotoxicity-induced apoptosis in rats after carbon monoxide exposure and that it had a protective effect. Other studies reported that resveratrol had many positive effects on hypertension, metabolism, and inflammatory processes. [5,9] Our literature review did not reveal any studies on the effect of resveratrol on heart failure after blunt chest trauma. Blunt chest trauma results in various types of damage, such as myocardial contusions, hematomas, ventricular rupture, ventricular septal defects, and valvular damage in the heart. Myocyte damage, hemorrhages, and edema may be observed at the microscopic level.[11] Blunt chest trauma also results in the onset of inflammatory processes and release of mediators, leading to life-threatening hemodynamic changes and arrhythmias. Heart injury after blunt chest trauma is associated with an increase in mortality rates.[10,11] The present study examined the anti-inflammatory efficacy of resveratrol in cardiac damage induced by blunt chest trauma. Previous research on the chain of reactions following blunt chest trauma reported a rapid increase in proinflammatory cytokines.[12] Research also showed that TNF-α levels increased in the presence of myocardial damage, such as cardiac arrest, sepsis, and multiple organ dysfunction syndromes and that blockade of TNF-α had a therapeutic effect.[23] In the present study, the immunoreactivity of TNF-α in the post-traumatic heart was severe, whereas the immunoreactivity of TNF-α in the resveratrol + trauma group was weak. Although various studies have drawn similar conclusions about the association of proinflammatory cytokines with the inflammatory process, there is discord concerning the effect of nitric oxide (NO). For example, Bradamante et al.[24] found that resveratrol reduced cardiac ischemia and reperfusion injury by upregulation of NO. Zhang et al.[4] reported that resveratrol was effective in endotoxemia-induced lung injury by reducing oxidative and nitric stress. They showed that resveratrol inhibited the formation of peroxynitrite by reducing iNOS expression and oxidative damage. NO played a key role in the maintenance of endothelial cell function. NO showed antioxidant properties by binding to superoxide groups, resulting in the formation of oxidants, such as peroxynitrite, which has a long half-life.[5] However, this did not have a significant effect on physiological conditions. Ulus Travma Acil Cerrahi Derg, July 2019, Vol. 25, No. 4

Previous research demonstrated that in pathological conditions, endotoxins, cytokines, and TNF-α induced a 10-fold increase in NO levels by triggering upregulation of iNOS, resulting in the production of NO and peroxynitrite and increased oxidative damage.[4,25] In the present study, the increase in TNF-α levels after trauma may have triggered iNOS formation. When the immunoreactivity of iNOS was evaluated, the most intense reaction occurred in the trauma group, whereas immunoreactivity in the resveratrol + trauma group was weak. Resveratrol showed anti-inflammatory and antioxidant properties by reducing TNF-α levels and iNOS production. The present study investigated the serum level of endocan in relation to the inflammatory process. Previous studies examined the association of endocan with heart disease.[13,26] In a study of 164 patients, Wang et al.[27] reported that serum levels of endocan were correlated with the presence and severity of coronary artery disease. Balta et al.[13] reported that vascular inflammation played an important role in the pathophysiology of hypertension and that the increased level of endocan may be indicative of untreated hypertension. Similar studies reported that endocan can be used as a biomarker in the diagnosis and follow-up of cardiovascular diseases.[13,26] They also suggested that endocan induced endothelial activation or dysfunction in endothelium-derived diseases and that it may serve as a biomarker of inflammation in diseases of vascular origin.[13–15] Although many studies concluded that an increase in the serum level of endocan was a sign of a worsening disease, there is discord in the literature on this topic. [13–15] Mikkelsen et al.[16] concluded that decreased endocan levels were associated with progression to acute lung injury in major trauma patients. They attributed this finding to a possible blockade of endocan-mediated leukocyte migration to the lung. In the present study, the increase in serum endocan levels was the same in both the trauma and resveratrol groups. The highest endocan level was observed in the resveratrol + trauma group. Post-traumatic endothelial activation may have triggered the release of endocan. However, the increase in endocan in the resveratrol group and resveratrol + trauma group in the present study cannot be explained based on the current findings. Although many investigators have suggested that endocan may serve as a biomarker in various diseases, in the present study, the serum endocan level was not correlated with the inflammatory process, as it was increased in both the only-trauma and resveratrol treatment groups. Natriuretic peptides are proteins released in the myocardium in response to overloading or pressure loading. The serum level of TnI is a biomarker of myocyte damage, with levels increasing after muscle damage.[28] Studies on the use of natriuretic peptides, either alone or together with TnI as biomarkers in the diagnosis of different cardiac diseases, are ongoing.[28,29] In a study conducted in 2015, Dogan et al.[28] evaluated NT pro-BNP and TnI levels in heart damage after blunt chest trauma in rats and reported that NT pro-BNP 347


Çağlar Torun et al. Assessing the therapeutic effect of resveratrol in heart failure following blunt chest trauma and the potential role of endocan

was significantly increased in the trauma group as compared with that of a control group. They suggested that NT proBNP could be used as a diagnostic test for heart failure after blunt chest trauma. In the present study, the histopathological examination revealed myocyte damage and necrotic areas in the trauma group. The severity of iNOS and TNF-α immunoreactivity/staining was significantly higher in the trauma group as compared to that of all the other groups. However, there was no significant difference between the groups in terms of NT pro-BNP and TnI levels. The time at which the blood samples were obtained may explain this finding. Dogan et al.[28] took blood samples in the 5th hour after trauma in their study. In the present study, blood samples were taken 24 hours after the induction of trauma in rats. Further research is needed to investigate the association between the time of blood sampling and the use of serum NT pro-BNP and TnI as a diagnostic test for cardiac injury in patients with blunt chest trauma.

Conclusion The present study showed that resveratrol had anti-inflammatory and antioxidant effects in lung injury after blunt chest trauma and that it contributed to the treatment process. The serum level of endocan was not correlated with the inflammatory process in either the trauma group or resveratrol + trauma group. We believe that there is a need for further studies on the clinical use of endocan as a biomarker of inflammation in cardiac disease. Conflict of interest: None declared.

REFERENCES 1. Raj P, Louis XL, Thandapilly SJ, Movahed A, Zieroth S, Netticadan T. Potential of resveratrol in the treatment of heart failure. Life Sci 2014;95:63–71. 2. Raj P, Zieroth S, Netticadan T. An overview of the efficacy of resveratrol in the management of ischemic heart disease. Ann N Y Acad Sci 2015;1348:55–67. 3. Catalgol B, Batirel S, Taga Y, Ozer NK. Resveratrol: French paradox revisited. Front Pharmacol 2012;3:141. 4. Zhang HX, Duan GL, Wang CN, Zhang YQ, Zhu XY, Liu YJ. Protective effect of resveratrol against endotoxemia-induced lung injury involves the reduction of oxidative/nitrative stress. Pulm Pharmacol Ther 2014;27:150–5. 5. Cho S, Namkoong K, Shin M, Park J, Yang E, Ihm J, et al. Cardiovascular Protective Effects and Clinical Applications of Resveratrol. J Med Food 2017;20:323–34. 6. Robich MP, Osipov RM, Chu LM, Han Y, Feng J, Nezafat R, et al. Resveratrol modifies risk factors for coronary artery disease in swine with metabolic syndrome and myocardial ischemia. Eur J Pharmacol 2011;664:45–53. 7. O’Leary KA, de Pascual-Teresa S, Needs PW, Bao YP, O’Brien NM, Williamson G. Effect of flavonoids and vitamin E on cyclooxygenase-2 (COX-2) transcription. Mutat Res 2004;551:245–54. 8. Miyazaki R, Ichiki T, Hashimoto T, Inanaga K, Imayama I, Sadoshima J, et al. SIRT1, a longevity gene, downregulates angiotensin II type 1 receptor expression in vascular smooth muscle cells. Arterioscler Thromb Vasc

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Biol. 2008;28:1263–9. 9. Ungvari Z, Labinskyy N, Mukhopadhyay P, Pinto JT, Bagi Z, Ballabh P, et al. Resveratrol attenuates mitochondrial oxidative stress in coronary arterial endothelial cells. Am J Physiol Heart Circ Physiol 2009;297:H1876– 81. 10. Emet M, Akoz A, Aslan S, Saritas A, Cakir Z, Acemoglu H. Assessment of cardiac injury in patients with blunt chest trauma. Eur J Trauma Emerg Surg 2010;36:441–7. 11. Demir F, Güzel A, Kat C, Karadeniz C, Akdemir U, Okuyucu A, et al. A combination of methylprednisolone and quercetin is effective for the treatment of cardiac contusion following blunt chest trauma in rats. Braz J Med Biol Res 2014;47:766–72. 12. De’Ath HD, Manson J, Davenport R, Glasgow S, Renfrew I, Davies LC, et al. Trauma-induced secondary cardiac injury is associated with hyperacute elevations in inflammatory cytokines. Shock 2013;39:415–20. 13. Balta S, Mikhailidis DP, Demirkol S, Ozturk C, Celik T, Iyisoy A. Endocan: A novel inflammatory indicator in cardiovascular disease? Atherosclerosis 2015;243:339–43. 14. Yang J, Yang Q, Yu S, Zhang X. Endocan: A new marker for cancer and a target for cancer therapy. Biomed Rep 2015;3:279–83. 15. Palmiere C, Augsburger M. Endocan measurement for the postmortem diagnosis of sepsis. Leg Med (Tokyo) 2014;16:1–7. 16. Mikkelsen ME, Shah CV, Scherpereel A, Lanken PN, Lassalle P, Bellamy SL, et al. Lower serum endocan levels are associated with the development of acute lung injury after major trauma. J Crit Care 2012;27:522.e11–7. 17. Torun AC, Tutuncu S, Ustun B, Akdemir HU. A Study of the Therapeutic Effects of Resveratrol on Blunt Chest Trauma-Induced Acute Lung Injury in Rats and the Potential Role of Endocan as a Biomarker of Inflammation. Inflammation 2017;40:1803–10. 18. Raghavendran K, Davidson BA, Helinski JD, Marschke CJ, Manderscheid P, Woytash JA, et al. A rat model for isolated bilateral lung contusion from blunt chest trauma. Anesth Analg 2005;101:1482–9. 19. Adams EJ, Green JA, Clark AH, Youngson JH. Comparison of different scoring systems for immunohistochemical staining. J Clin Pathol 1999;52:75–7. 20. True LD. Principles of immunohistochemistry. In: True LD, ed. Atlas of Diagnostic Immunohistopathologhy. NewYork: Gower Medical Publishing; 1990. p. 16–22. 21. Zheng H, Guo H, Hong Y, Zheng F, Wang J. The effects of age and resveratrol on the hypoxic preconditioning protection against hypoxiareperfusion injury: studies in rat hearts and human cardiomyocytes. Eur J Cardiothorac Surg 2015;48:375–81. 22. Hashemzaei M, Barani AK, Iranshahi M, Rezaee R, Tsarouhas K, Tsatsakis AM, et al. Effects of resveratrol on carbon monoxide-induced cardiotoxicity in rats. Environ Toxicol Pharmacol 2016;46:110–15. 23. Hranjec T, Swenson BR, Dossett LA, Metzger R, Flohr TR, Popovsky KA, et al. Diagnosis-dependent relationships between cytokine levels and survival in patients admitted for surgical critical care. J Am Coll Surg 2010;210:833–44. 24. Bradamante S, Barenghi L, Piccinini F, Bertelli AA, De Jonge R, Beemster P, et al. Resveratrol provides late-phase cardioprotection by means of a nitric oxide- and adenosine-mediated mechanism. Eur J Pharmacol 2003;465:115–23. 25. Roberts RA, Laskin DL, Smith CV, Robertson FM, Allen EM, Doorn JA, et al. Nitrative and oxidative stress in toxicology and disease. Toxicol Sci 2009;112:4–16. 26. Kundi H, Balun A, Cicekcioglu H, Karayigit O, Topcuoglu C, Kilinckaya MF, et al. Admission Endocan Level may be a Useful Predictor for InHospital Mortality and Coronary Severity Index in Patients With STSegment Elevation Myocardial Infarction. Angiology 2017;68:46–51. 27. Wang XS, Yang W, Luo T, Wang JM, Jing YY. Serum endocan levels are correlated with the presence and severity of coronary artery disease in

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29. Cheng H, Fan WZ, Wang SC, Geng J, Zang HL, Shen XH, et al. Prognostic utility of combination of NT-proBNP with high sensitive cTn I in patients with heart failure: Results from retrospective study in an emergency department. Scand J Clin Lab Invest 2016;76:361–7.

DENEYSEL ÇALIŞMA - ÖZET OLGU SUNUMU

Sıçanlarda künt göğüs travma sonrası oluşan kalp hasarı üzerine resveratrolün tedavi edici etkisinin ve endokanın enflamasyonda bir biyobelirteç olarak potansiyel rolünün değerlendirilmesi Dr. Aysun Cağlar Torun,1 Dr. Şerife Tütüncü2 1 2

Ondokuz Mayıs Üniversitesi Diş Hekimliği Fakültesi, Ağız Diş ve Çene Cerrahisi Anabilim Dalı, Samsun Ondokuz Mayıs Üniversitesi Veterinerlik Fakültesi, Histoloji Anabilim Dalı, Samsun

AMAÇ: Bu çalışma, sıçanlarda künt göğüs travmasına bağlı gelişen kardiyak hasar üzerine resveratrolün terapötik etkisini ve endokanın enflamasyon sürecinde bir biyobelirteç olarak kullanılmasını araştırmıştır. GEREÇ VE YÖNTEM: Sıçanlar randomize olarak aşağıdaki dört gruba ayrıldı (her grupta, n=7): bir kontrol grubu (tedavi veya travma olmadan); travma uygulanan grup (travma grubu); resveratrol grubu (resveratrol, [0.3 mg/kg] intraperitoneal [i.p.] yol grubu yoluyla uygulandı); ve resveratrol + travma grubu (travmanın uygulanmasından 1 saat önce i.p. yolla resveratrol [0.3 mg/kg] verilen). BULGULAR: Travma grubundaki tümör nekroz faktörü-α ve indüklenebilir nitrik oksit sentazın immünreaktivitesi artarken, resveratrol + travma grubundaki reaksiyon şiddeti azaldı. Grupların ortalama endokan değerleri farklıydı (p<0.001). Resveratrol + travma grubundaki ortalama endokan ortalaması diğer gruplardan daha yüksekti. TARTIŞMA: Resveratrol, künt göğüs travması sonrası akciğer hasarında anti-enflamatuvar ve antioksidan etkilere sahip olup tedavi sürecine katkıda bulunmuştur. Künt göğüs travması sonrası oluşan kardiyak hasarda enflamasyonun takibinde endokanın bir biyobelirteç olarak klinik kullanımı ile ilgili daha fazla çalışma yapılması gerektiğine inanıyoruz. Anahtar sözcükler: Endokan; kalp hasarı; künt göğüs travması; resveratrol. Ulus Travma Acil Cerrahi Derg 2019;25(4):343-349

doi: 10.5505/tjtes.2018.77246

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ORIG I N A L A R T IC L E

Role of angiotensin-converting enzyme as prognostic marker in thoracic trauma: A prospective observational study Suresh Kumar, M.S.,1 Ajay Kumar Pal, M.S.,1 Arvind Kumar Suman, M.S.,1 Sanjeev Kumar, M.S.,1 Ganesh Chandra Yadav, M.S.,1 Mohd. Kaleem Ahmad, M.S.2 1

Department of Surgery, King George’s Medical University, Lucknow-India

2

Deapartment of Biochemistry, King George’s Medical University, Lucknow-India

ABSTRACT BACKGROUND: Chest injuries, accounting for 25% of all trauma-related deaths, are one of the main causes of death in young adults. Our priority is the early identification of life-threatening injuries both immediate and delayed. The role of various biomarkers, such as Clara cell protein 16, von Willebrand factor, interleukin-6, tumor necrosis factor, and angiopoietin, has been studied in trauma-related acute respiratory distress syndrome (ARDS). Serum angiotensin-converting enzyme (ACE) levels have been studied in non-trauma-related ARDS. The aim of this prospective observational study was to evaluate the role of ACE levels as a prognostic marker in thoracic trauma. METHODS: A prospective observational study was conducted to evaluate serum ACE levels in thoracic trauma patients and to explore its prognostic potential with regard to clinical outcome. A total of 48 thoracic trauma patients were included in the study. RESULTS: The mean ACE level in the study population was 66.54±11.18. A strong positive correlation was found among serum ACE levels and Thoracic Trauma Severity Score (TTSS). CONCLUSION: Our study demonstrates that serum ACE levels are increased in thoracic trauma patients with higher levels, indicating the severe nature of trauma in concordance with increased TTSS scores. Keywords: Angiotensin-converting enzyme; chest; injury; marker; prognosis.

INTRODUCTION Chest injuries, accounting for 25% of all trauma-related deaths, are one of the main causes of death in young adults.[1] These injuries can be managed by pain management, oxygenation, tube thoracostomy, or surgery. Mortality can occur immediately after thoracic injury or in the delayed phase due to respiratory failure.[1] The early identification of patients with trauma-related acute respiratory distress syndrome (ARDS) with grave prognosis is of utmost importance, and various biomarkers in blood and bronchoalveolar lavage fluid have been studied till date in this regard, e.g., Clara cell protein 16, von Willebrand factor, interleukin-6, tumor necrosis factor, angiopoietin-2, histones, selectins, and mitochondrial DNA. [2–7] In this respect, angiotensin-converting enzyme (ACE),

which plays a central role in generating angiotensin II from angiotensin I in the renin–angiotensin system (RAS), assumes importance because the capillary blood vessels in the lung are one of the major sites of ACE expression and angiotensin II production in the human body.[8] Though the role of RAS has been implicated in the pathogenesis of pulmonary hypertension and pulmonary fibrosis in chronic lung diseases,[9] recent studies indicate that the RAS also plays a critical role in acute lung injury and ARDS.[9] Thoracic trauma also increases the chances of acute lung injury and ARDS with or without fatality. Thus, the RAS appears to play a critical role in the pathogenesis of trauma-related acute lung injury. Therein lie the possibility of therapeutic altering of ACE activity to affect the prognostic outcome in severe thoracic trauma. Therefore, we planned a prospective observational study to

Cite this article as: Kumar S, Pal AK, Suman AK, Kumar S, Yadav GC, Ahmad MK. Role of angiotensin-converting enzyme as prognostic marker in thoracic trauma: A prospective observational study. Ulus Travma Acil Cerrahi Derg 2019;25:350-354. Address for correspondence: Sanjeev Kumar, M.D. Department of Surgery, King George’s Medical University 22600 Lucknow - India Tel: 05222258180 E-mail: drsanjeevkgmc@gmail.com Ulus Travma Acil Cerrahi Derg 2019;25(4):350-354 DOI: 10.5505/tjtes.2018.14894 Submitted: 10.07.2018 Accepted: 23.10.2018 Online: 07.08.2019 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

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Kumar et al. Role of angiotensin-converting enzyme as prognostic marker in thoracic trauma

evaluate the levels of ACE in traumatic lung injury patients and to compare its level with Thoracic Trauma Severity Score (TTSS). We correlate the level of ACE with the outcome (discharge, ARDS, and mortality) of patients, so that its role can be established as a predictive marker for the severity and prognosis of traumatic parenchyma lung injury.

MATERIALS AND METHODS After obtaining approval from the institutional ethical committee, this prospective observational study was conducted in the Department of Surgery, in collaboration with the Department of Biochemistry. All consecutive adult (aged >18 years) patients of isolated lung injury (blunt or penetrating) coming to the trauma center and surgery emergency of King George Medical University Lucknow, UP, India from July 2015 to August 2016 were included in the study. Informed consent was obtained from the patients. Patients with polytrauma, pre-existing pulmonary or renal disease, and any other significant co-morbid medical or surgical illness were excluded from the study. The demographic data of all patients, mode of injury, any intervention, serum ACE levels at the time admission, and outcomes (discharge, ARDS, and mortality) were evaluated.

Data Collection After performing a thorough clinical examination, noting down associated injuries along with exclusion of patients with obvious polytrauma, chest radiograph examination and ultrasonography (focused assessment with sonography in trauma) abdomen with exclusion of patients with abdominal trauma were performed. Patient’s clinical condition guided by laboratory parameters and radiological investigations was the main determinant of further management as per standard practice guidelines for thoracic trauma followed upon in the institution, and it was not affected by the observational nature of the study.

Procedure Venous blood sample (5 mL) was withdrawn from patients with traumatic lung injury on the day of admission and stored in a deep freezer at −80 °C. It was transported in an icebox to the Department of Biochemistry for storage at −80 °C. It was centrifuged at 3000 g for 10 min for separation of serum. The estimation of serum ACE by enzyme linked immunosorbent assay (ELISA) kit was performed according to the manufacturer’s protocol.

Statistical Analysis Student’s t-test was used to test the significance of the mean of two groups, and paired t-test was used to test the significance of change in variable. Chi-square test was used to test the significance of contingency tables. Values are expressed as mean and standard deviation. A p value <0.05 was accepted as significant. Ulus Travma Acil Cerrahi Derg, July 2019, Vol. 25, No. 4

RESULTS Demographic Profile of the Patients The duration of the study was 1 year. A total of 48 patients with isolated traumatic lung injury (by both penetrating and blunt trauma) were enrolled into the study. The mean age of the patients was 41.48±4.37 (range 13–70) years. The majority of the patients were male, with a study population of 44 (91.67%). A bimodal distribution of age was seen at maximum (n=10, %=21) between 21 and 30 years and 51 and 60 years, followed by those aged between 41 and 50 years (n=9, %=19).

Injury Pattern Road traffic accident (n=26, %=54) followed by fall from height (n=12, %=25) were common modes of injury, whereas penetrating trauma by sharp objects (low velocity), firearm chest injury (high velocity), and bull horn injury were other modes of injury (Table 1). In most of the patients, lung contusion alone was the most consistent finding (50%), followed by contusion and collection of both (31%). The rest of them had collection alone (6%), subcutaneous emphysema (16%), pneumothorax (2%), and subcutaneous hematoma (2%) (Table 1).

Serum ACE Levels The serum level of ACE in different patients was evaluated by using an ELISA kit, and the value varied between 30 and 90 µg/L. The mean ACE levels in our patient was 66.54±11.18. Six range groups were made viz. ≤40, 41–50, 51–60, 61–70, 71–80, and >80. Most of the patients had levels 61–70 (41%), followed by 71–80 (31%) (Table 1).

Thoracic Trauma Severity Score TTSS, which consists of five grades based on PaO2/FiO2 ratio, rib fracture, contusion of the lung, pleural involvement, and age of the patient, was calculated in each patient. The mean TTSS score was 8.52±4.42 (Table 1).

Correlation of Serum ACE with the Length of Hospital Stay, Complications, and Outcome Patients with the highest duration of hospital stay (mean 16.4±3.26 days) had higher ACE levels in the range of 71–80 µg/L, and those with the least duration of stay (2 days) had ACE levels <40 µg/L (Table 2, Fig. 1). Patients with ACE levels >80 µg/L had lesser hospital stay with higher incidence of expiry among them. Patients without complications had a mean level of ACE of 63.1, whereas those with complications of pneumonitis, empyema thoracis, ARDS, and sepsis had mean levels of ACE (µg/L) of 66.4, 75.3, 76.1, and 87.5, respectively (Fig. 2).

Correlation of TTSS with the Length of Hospital Stay, Complications, and Outcome Patients with the highest duration of hospital stay (mean 13.4 days) had higher TTSS in the range of 11–15, but TTSS was 351


Kumar et al. Role of angiotensin-converting enzyme as prognostic marker in thoracic trauma

Table 1. Patient characteristics, demographics, injury pattern, complications, ACE levels, TTSS scores, and final outcome

n

%

Age (years) Sex, males

44

Mean±SD 41.48±4.37

91.6

Length of hospital stay, days

8.95±3.54

Mode of injury

Road traffic accident

26

54

Fall from height

12

25

Penetrating trauma (low velocity)

3

6.25

Penetrating trauma (high velocity)

3

6.25

4

8.33

Others Type of thoracic injury

Pleural collection (only)

3

Pulmonary contusion (only)

24

Pleural collection and pulmonary contusion

15

Pneumothorax (only)

Subcutaneous hematoma (only)

3

Rib fractures with other associated pleuro-parenchymal injuries

39

No chest wall or pleuro-parenchymal injury

3

Complications

No complication

Pneumonitis

34 2

Empyema thoracis

2

Adult respiratory distress syndrome

9

Sepsis

1

Serum ACE levels, µg/ML

66.54±11.18

Range of ACE levels, duration of stay (days) ≤40

1

2.08

2.0±0

41–50

2

4.16

3.5±1.0

51–60

7

14.58

5.85±0.90

61–70

20

41.66

7.55±1.23

71–80

15

31.25

16.4±3.26

>80

3

6.25

TTSS scores

9.0±1.0 8.52±4.42

Range of TTSS 0–5

10

20.83

5.0±1.63

6–10

22

45.83

8.05±1.99

11–15

13

27.08

13.4±3.53

16–20

3

6.25

9.0±1.0

Discharge

42

87.5

Ventilation

3

6.25

Expiry

3

6.25

Final outcome

ACE: Angiotensin-converting enzyme; TTSS: Thoracic Trauma Severity Score; SD: Standard deviation.

highest (16–20) in patients with a duration of stay of 9.0±1 days due to the higher incidence of expiry (Fig. 1). Patients 352

without complications had a mean value of TTSS of 7.2, whereas those with complications of pneumonitis, empyema Ulus Travma Acil Cerrahi Derg, July 2019, Vol. 25, No. 4


Kumar et al. Role of angiotensin-converting enzyme as prognostic marker in thoracic trauma

ACE level (µg/L) Expired

Duration of stay (days) 80.2

2.8

Ventilatory support

75.01

19.3

Discharged

64.9

9.4

0

10

20

30

40

50

60

70

80

90

Figure 1. Serum ACE levels, patient outcome, and length of stay. ACE levels (µg/L) Shock ARDS

76.1 76.1

13

Empyema thoracis

75.3

11.5

Pneumonitis

66.4

9

Non compicated

63.1

7.2

0

Serum ACE level may be potentially altered in thoracic trauma as pulmonary capillaries being the site of expression of ACE may be damaged in thoracic trauma. In a previous study by Orfanos et al.,[14] pulmonary capillary endothelium band ACE was altered in 22 critically ill patients with a decrease in early stage acute lung injury. However, their study was conducted in an intensive care unit setting and critically ill patient only. In our prospective study, we have performed an evaluation of serum ACE levels, which were hypothesized to be increased as a result of pulmonary endothelial damage in severe thoracic trauma.

TTSS

17

10

20

30

40

50

60

70

80

Figure 2. Serum ACE levels and complications. 100

Serum ACE levels

90 80 70 60 50 40 30 20 10 0

0

2

4

6

8 10 12 TTSS scores

14

16

18

20

Figure 3. Correlation of TTSS and serum ACE levels.

thoracis, ARDS, and sepsis had mean levels of TTSS of 9, 11.5, 13, and 17 respectively (Fig. 1). When TTSS value was calculated for each patient, most of the patients had a range of TTSS of 6–10 (45%), followed by ranges of 11–15 (27%) and 0–5 (20%) (Fig. 2).

Correlation of TTSS with Serum ACE Levels On correlating TTSS and serum ACE in our patients, a strong positive correlation was found (coefficient of determination=0.86) (Fig. 3).

DISCUSSION Our prospective observational study on 48 patients with isoUlus Travma Acil Cerrahi Derg, July 2019, Vol. 25, No. 4

lated thoracic trauma severity and ACE levels indicates that serum ACE level is increased in patients with severe thoracic trauma, complications (pneumonitis, empyema thoracis, ARDS, and sepsis), and mortality. It was also suggested that serum ACE level with a high correlation with TTSS may play a potential biomarker role for injury severity in thoracic trauma. Though there are several studies conducted on biomarkers of lung injury in ARDS, most of these were performed on nontraumatic causes of ARDS[10–13] with in critical care settings and based on retrospective collection of data. Prospective studies on a novel biomarker, such as serum ACE, for prognostication of thoracic trauma patients are still lacking. Thus, the search of a biomarker for lung injury in thoracic trauma is still ongoing.

Various scoring systems, such as TTSS and Lung Organ Failure Score, have been used to predict the risk fraction of ARDS in trauma settings. In our study, we have also found an increased TTSS score in patients with complications of thoracic trauma, and a significant positive correlation was found between serum ACE levels and TTSS scores. This suggests the role of serum ACE levels as a potential prognostic marker. The main limitation of our study is its small sample size and the non-inclusion of any radiological investigation (e.g., multiple detector computed tomography) for the evaluation of the extent of pulmonary change. One more point worth mentioning is that ACE level may be increased in inflammatory disorders, such as sarcoidosis and other medical conditions, such as diabetes, cirrhosis, hyperthyroidism, psoriasis, amyloidosis, human immunodeficiency virus, histoplasmosis, leprosy, lymphoma, and tuberculosis. Though we have excluded patients with medical disorders from our study, there is still a chance of false positive results. Future prospective studies with larger sample size with possible multi-institutional involvement and utilization of multiple regression analysis based on the prediction of risk outcome after consideration of clinical, radiological, and biochemical marker of thoracic injury along with various injury scoring systems are required for validation of our results. Nevertheless, to the best of our knowledge, this is probably the first study to evaluate the role of ACE as a prognostic marker in thoracic trauma patients.

Conclusion Our study demonstrates that serum ACE levels are increased in thoracic trauma patients with higher levels, thereby indicat353


Kumar et al. Role of angiotensin-converting enzyme as prognostic marker in thoracic trauma

ing the severe nature of trauma in concordance with increased TTSS scores. Thus, there exists a potential role of serum ACE levels as a prognostic marker in thoracic trauma. However, future studies are needed to support this conclusion. Conflict of interest: None declared.

REFERENCES 1. Nirula R, Pintar FA. Identification of vehicle components associated with severe thoracic injury in motor vehicle crashes: a CIREN and NASS analysis. Accid Anal Prev 2008;40:137−41. 2. Kumar S, Pandey A, Kumar S, Singh SP, Ahmad A, Ahmad MK. Diagnostic and prognostic efficacy of Von Willebrand factor and Clara cell in traumatic lung injury. Indian J Thorac Cardiovasc Surg 2018;34: 125−8. 3. Agrawal A, Matthay MA, Kangelaris KN, Stein J, Chu JC, Imp BM, et al. Plasma angiopoietin-2 predicts the onset of acute lung injury in critically ill patients. Am J Respir Crit Care Med 2013;187:736−42. 4. Calfee CS, Gallagher D, Abbott J, Thompson BT, Matthay MA; NHLBI ARDS Network. Plasma angiopoietin-2 in clinical acute lung injury: prognostic and pathogenetic significance. Crit Care Med 2012;40:1731−7. 5. Zhang Y, Guan L, Yu J, Zhao Z, Mao L, Li S, et al. Pulmonary endothelial activation caused by extracellular histones contributes to neutrophil activation in acute respiratory distress syndrome. Respir Res 2016;17:155. 6. Donnelly SC, Haslett C, Dransfield I, Robertson CE, Carter DC, Ross

JA, et al. Role of selectins in development of adult respiratory distress syndrome. Lancet 1994;344:215−9. 7. Gan L, Zhong J, Zhang R, Sun T, Li Q, Chen X, et al. The Immediate Intramedullary Nailing Surgery Increased the Mitochondrial DNA Release That Aggravated Systemic Inflammatory Response and Lung Injury Induced by Elderly Hip Fracture. Mediators Inflamm 2015;2015:587378. 8. Biller H, Zissel G, Ruprecht B, Nauck M, Busse Grawitz A, MüllerQuernheim J. Genotype-corrected reference values for serum angiotensin-converting enzyme. Eur Respir J 2006;28:1085−90. 9. Guang C, Phillips RD, Jiang B, Milani F. Three key proteases--angiotensinI-converting enzyme (ACE), ACE2 and renin-within and beyond the renin-angiotensin system. Arch Cardiovasc Dis 2012;105:373−85. 10. Khan A, Benthin C, Zeno B, Albertson TE, Boyd J, Christie JD, et al. A pilot clinical trial of recombinant human angiotensin-converting enzyme 2 in acute respiratory distress syndrome. Crit Care 2017;21:234. 11. Lesur O, Langevin S, Berthiaume Y, Légaré M, Skrobik Y, Bellemare JF, et al. Outcome value of Clara cell protein in serum of patients with acute respiratory distress syndrome. Intensive Care Med 2006;32:1167−74. 12. Yan Y, Rao Q. Biomarkers in the diagnosis and prognostic assessment of acute respiratory distress syndrome. J Transl Intern Med 2014;2:160–3. 13. Determann RM, Millo JL, Waddy S, Lutter R, Garrard CS, Schultz MJ. Plasma CC16 levels are associated with development of ALI/ARDS in patients with ventilator-associated pneumonia: a retrospective observational study. BMC Pulm Med 2009;9:49. 14. Orfanos SE, Langleben D, Khoury J, Schlesinger RD, Dragatakis L, Roussos C, et al. Pulmonary capillary endothelium-bound angiotensinconverting enzyme activity in humans. Circulation 1999;99:1593−9.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Toraks travmasında bir prognostik belirteç olarak anjiyotensin dönüştürücü enzimin rolü: Bir ileriye yönelik gözlemsel çalışma Dr. Suresh Kumar,1 Dr. Ajay Kumar Pal,1 Dr. Arvind Kumar Suman,1 Dr. Sanjeev Kumar,1 Dr. Ganesh Chandra Yadav,1 Dr. Mohd. Kaleem Ahmad2 1 2

Kral George’s Tıp Üniversitesi, Cerrahi Anabilim Dalı, Lucknow-Hindistan Kral George’s Tıp Üniversitesi, Biyokimya Anabilim Dalı, Lucknow-Hindistan

AMAÇ: Toraks yaralanmaları tüm travma nedenli ölümlerin %25’inden sorumlu olup genç yetişkinlerde ölümün başlıca nedenlerinden biridir. Önceliğimiz hem travmanın hemen sonrası hem de geç dönemde yaşamı tehdit edici yaralanmaların erkenden tanımlanmasıdır. Clara hücre proteini 16, von Willebrand faktörü, interlökin-6, tümör nekroz faktörü ve anjiyopoietin gibi değişik biyobelirteçlerin rolü travmayla ilişkili akut solunum sıkıntısı sendromunda (ASSS) incelendi. Serum anjiyotensin dönüştürücü enzim (ADE) düzeyleri travmayla ilişkili olmayan ASSS’de çalışıldı. Bu ileriye yönelik gözlemsel çalışmada, totraks travmasında bir prognostik belirteç olarak ADE düzeylerinin rolü değerlendirildi. GEREÇ VE YÖNTEM: Toraks travma hastalarında serum ADE düzeylerini değerlendirme ve klinik sonuç açısından prognostik potansiyelini araştırma amacıyla bir ileriye yönelik gözlemsel çalışma yürütüldü. Çalışmaya toplam 48 toraks travma hastası dahil edildi. BULGULAR: Çalışma popülasyonunda ortalama ADE değeri 66.54±11.18 U/L idi. Serum ADE düzeyleri ve Toraks Travması Şiddet Skoru (Thoracic Trauma Severity Score: TTSS) arasında güçlü bir korelasyon saptandı. TARTIŞMA: Çalışmamız serum ADE düzeylerinin toraks travması hastalarında yükseldiğini, şiddetli travmanın yüksek TTSS’yle uyum içinde olduğunu göstermektedir. Anahtar sözcükler: Anjiyotensin dönüştürücü enzim; belirteç; prognoz; toraks; yaralanma. Ulus Travma Acil Cerrahi Derg 2019;25(4):350-354

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doi: 10.5505/tjtes.2018.14894

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ORIG I N A L A R T IC L E

Role of ultrasonography in determining the cricothyroid membrane localization in the predicted difficult airway Demet Altun, M.D.,1 Achmet Ali, M.D.,1 Kemalettin Koltka, M.D.,1 Mehmet Çelik, M.D.,2 Can Doruk, M.D.,2 Ali Emre Çamcı, M.D.1

Mehmet Büget, M.D.,1

1

Department of Anesthesiology and Reanimation, İstanbul University İstanbul Faculty of Medicine, İstanbul-Turkey

2

Department of Otolaryngology, Head and Neck Surgery İstanbul University İstanbul Faculty of Medicine, İstanbul-Turkey

ABSTRACT BACKGROUND: The aim of this study was to investigate the success rates of ultrasound (US) and palpation methods in identifying the cricothyroid membrane (CTM), and compare the results with the gold standard method—computed tomography (CT) scan. METHODS: A total of 110 patients were included into the study. The midline was estimated by a single investigator using both the US and palpation methods from the prominence of the thyroid cartilage to the center of the sternal notch, and the distance was measured (in millimeters) between the two points: Point A (the midpoint of CTM) and Point B (the inferior process of thyroid cartilage). Furthermore, the distance between Point A and Point B was calculated using the CT images. Time taken to assess the CTM by using US and palpation methods were recorded. Moreover, difficulty in using the two methods was measured with the visual analog scale (VAS). In addition, demographic and morphometric characteristics of the patients were noted. RESULTS: The CTM was detected accurately in 50 (45.5%) patients with palpation and 82 (74.5%) with US. In the Bland–Altman analysis, a better agreement was observed with US. The time to assess CTM was shorter with US than with palpation, p<0.001. The VAS scores for the palpation and US difficulty were 5.13±1.1 and 3.32±0.9 (p<0.001), respectively. While an increased neck circumference and thyromental distance were found to be independent risk factors for the success rates of determining the CTM by palpation, body mass index is an independent risk factor for US. CONCLUSION: Localization of the CTM is more accurate and easier with US than palpation. Furthermore, the results gathered with US are in a closer range to CT scan. Keywords: Airway management; cricoid cartilage; thyroid cartilage; ultrasound imaging.

INTRODUCTION The cricothyroid membrane (CTM), located in the anterior neck between cricoid and thyroid cartilages, is the emergency cricothyroidotomy site of puncture. Emergency cricothyroidotomy, although rarely performed, is the “fail-safe” step in cases of “cannot intubate, cannot oxygenate” (CICO) scenarios, when all previous options for the noninvasive establishment of airway have failed (Difficult Airway Society, DAS). The CICO scenario is relevant to anesthesiologists as this situation is accountable in approximately 25% of anesthesi-

a-related deaths.[1,2] Yet, cricothyroidotomy performed in emergency situations has a high failure rate (up to 30%), and it takes a longer period of time, which causes further problems in an already desaturated patient. It is noteworthy that this failure is frequently associated with tube misplacement.[3] Hence, a correct technique and an accurate identification of the precise localization of CTM before performing cricothyroidotomy are crucial to prevent further morbidity (laryngotracheal injury) and mortality (death). Thus, improving skills to locate this membrane is of

Cite this article as: Altun D, Ali A, Koltka K, Büget M, Çelik M, Doruk C, et al. Role of ultrasonography in determining the cricothyroid membrane localization in the predicted difficult airway. Ulus Travma Acil Cerrahi Derg 2019;25:355-360. Address for correspondence: Demet Altun, M.D. İstanbul Üniversitesi İstanbul Tıp Fakültesi, Anesteziyoloji ve Reanimasyon Anabilim Dalı, İstanbul, Turkey Tel: +90 212 - 414 20 00 / 31742 E-mail: drdemetaltun@hotmail.com Ulus Travma Acil Cerrahi Derg 2019;25(4):355-360 DOI: 10.14744/tjtes.2019.65250 Submitted: 29.11.2018 Accepted: 08.03.2019 Online: 15.04.2019 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

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Altun et al. Role of US in determining the CTM localization in the predicted difficult airway

utmost importance for anesthesiologists, otolaryngologists, and emergency physicians. The traditional method to identify CTM is palpation. The palpation of CTM can be achieved externally without any incision. However, in some cases, it is not possible for physicians to palpate the membrane. The suggested line of action by the DAS 2015 guidelines is to make a vertical incision at the level of the cricoid cartilage and perform a finger dissection until the membrane is exposed.[4] Previous studies have indicated that the success rates of palpation show great variations and are heavily affected by gender, body mass index (BMI), and position.[5,6] The average success rate is 72% for non-obese and 39% for obese males,[5] whereas it is 71% for non-obese[6] and 39% for obese females.[7] Ultrasound (US) has remarkably improved the success rate of the CTM identification ( 95%–100%)[8,9] and decreased the complication rates.[7] However, the clinical efficacy of the US guidance to identify the CTM is unclear compared to computed tomography (CT), which is a commonly used radiological technique and allows an accurate identification of the airway structures.[10] The aim of this prospective clinical study was to investigate the success rates of US and conventional finger palpation methods in identifying the cricothyroid membrane (CTM) and comparing the precision of identifying the CTM against the commonly used radiological technique—the CT scan. The time taken to assess CTM using the US and finger palpation methods and the difficulty of using these methods and factors associated with the success rates while determining the CTM localization were the secondary outcomes.

MATERIALS AND METHODS

One investigator (A.A.) was asked to identify the CTM by using both the finger palpation technique and US in the brightness (B) mode using a 12 MHz linear probe (GE Healthcare LOGIQ e ultrasound), and to point out the margins of the CTM with a board marker. The assessment was performed by a single investigator who had experience in the managing of difficult airway and ultrasonographic evaluation of airway. A PowerPoint presentation of 20 minutes on the US airway anatomy and CTM detection was also used to revise the important points prior to initiating the study. The midline was identified by drawing a line from the prominence of the thyroid cartilage to the center of the sternal notch, and all measurements and markings were performed at midline. The primary outcome was the distance measured in millimeters between the two points: Point A (the midpoint of CTM) and Point B (the inferior process of the thyroid cartilage where the CTM attaches). The points were marked by the investigator using US or palpation (Fig. 1). After each attempt, the accuracy of the estimate points of the investigator was also confirmed or refuted by an attending anesthesiologist experienced in airway ultrasonography (DA). The distance between Point A and Point B was also calculated by using the CT images with the InSight Picture Archiving and Communication System in the midline sagittal plane by an experienced consultant radiologist. The time required to assess the CTM by US was defined as the time from the first contact of the US probe with the skin to the marking of the CTM. In the case of palpation, it was defined as the time from the beginning of palpation of the skin to the marking of the CTM. The time measurements were reported.

Study Population and Setting A clinical study approval was obtained from the Institutional Ethics Committee (2016/84). Patients aged 18–65 years who received general anesthesia for any kind of neck surgery and who had previous neck CT images present were screened during the 4-month period for this study. Written consent was obtained from the patients prior to surgery. Patients who could not lay in the supine position or keep their head in the neutral position and patients whose CT scans did not include CTM were excluded from the study. After the premedication with oral midazolam at a dose 0.5 mg/kg, the patient was taken to the operating room, and standard monitoring (ECG, SPO2, and non-invasive arterial pressure) was applied. A standard anesthesia regimen was induced, and intubation was applied successfully to all patients.

Thyroid Cartilage Cricoid Cartilage Sternal Notch

Data Collection Patients were placed in the supine position with the head in the neutral position. 356

Figure 1. Image of landmarks of the thyroid cartilage, cricoid cartilage, and sternal notch marked on a female patient.

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Altun et al. Role of US in determining the CTM localization in the predicted difficult airway

The participating investigator was also asked to assess the ease of US and palpation method by using a 10 cm visual analog scoring (VAS) scale where 0 represented the easiest and 10 the most difficult. In addition, demographic data (age, gender, BMI); the neck circumference (cm; at the level of the thyroid cartilage); thyromental distance (mm; the distance from the mentum to the thyroid notch); sternomental distance (mm; the distance from the suprasternal notch to the mentum); mouth opening (cm; inter-incisor distance—the distance between the upper and lower incisors); the Mallampati classification;[11] and Cormach–Lehane scores[12] were noted.

The accuracy of detecting CTM with US (in 82 patients [74.5 %]) was significantly more successful than with palpation (in 50 patients [45.5%]) (p<0.05) (Table 2). In the Bland–Altman analysis, a bias of 2.79 mm was detected between palpation and CT (95% limits of agreement, 0.55– 5.03 mm) (Fig. 3a). In the Bland–Altman analysis, a bias of 0.73 mm was detected between US and CT (95% limits of agreement, 0.58–2.04 mm] (Fig. 3b).

Statistical Analysis

The Bland–Altman analysis was used to further assess the similarity of methods, and the range of agreement was defined as the mean bias and 95% confidence interval (CI). A binary logistic regression analysis was used for the risk analysis for gender, BMI, thyromental distance, sternomental distance, neck circumference, mouth opening, the Mallampati classification, and the Cormach–Lehane scores. The odds ratio (OR) and 95% CI were listed for detected independent risk factors.

Assessed for eligibilty (n=117)

Enrollment

Continuous data were presented as the mean±standard deviation (SD), median (min–maximum), or the number of patients (% incidence). The Mann–Whitney U test was used for the comparison of quantitative variants. Qualitative variants were compared using the chi-square test or the Fischer exact test, as appropriate. A p-value <0.05 was considered statistically significant.

Analyzed (n=110)

(a) 1 0

Sample Size Calculation

-5

In this study, 117 patients undergoing neck surgery were screened between February and May 2016. Two patients who refused to participate in the study, 2 patients who could not lay down in a neutral position due to mild chronic obstructive pulmonary disease, and 3 patients who did not have a preoperative CT scan documenting CTM were excluded from the study. Data from the remaining 110 patients were included in the statistical analysis (Fig. 2). The demographic and morphometric characteristics of the patients are presented in Table 1. Ulus Travma Acil Cerrahi Derg, July 2019, Vol. 25, No. 4

+1.96 SD -0.5

-1 -2

RESULTS

Excluded (n=5) • Did not include CTM image (n=3) • Could not be able to lay in neutral position (n=2)

Figure 2. Study flow diagram.

Data were analyzed using the MedCalc Statistical Software version 12.7.7 (MedCalc Software bvba, Ostend, Belgium; www.medcalc.org; 2013).

The sample size was calculated according to the primary outcome. Bland and Altman[13] recommended that at least 100 patients be included in the analysis, so that a calculation can be achieved with the 95% CI ± 0.34 s, which is the SD of the differences between measurements by the two methods. The required numbers of screened volunteers were achieved at the end of the 4 month.

Refused to participate (n=2)

Mean -2.8

-2 -4

-6

-1.96 SD -5.0 0

1

2 3 4 5 Agreement between CT and palpation

(b)

6

7

1.0 +1.96 SD 0.58

0.5 0.0 -0.5

Mean -0.73

-1.0 -1.5

-1.96 SD -2.04

-2.0 -2.5

0

1

2

3

4

5

6

Agreement between CT and US

Figure 3. Agreement between different methods. (a) Agreement between CT and palpation. (b) Agreement between CT and US.

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Altun et al. Role of US in determining the CTM localization in the predicted difficult airway

Table 1. Demographic and morphometric characteristics of the patients Variable

Data (n=110)

Age (years)

63.3±10.25

Gender

Male

80 (72.7%)

Female

30 (27.3%)

Body mass index (kg/m2) 28.2±3.66 Neck circumference (cm)

42±3.76

Thyromental distance (cm)

6.08±0.14

Sternomental distance (cm)

11.4±0.23

Mouth opening (cm)

5.2±0.07

Mallampati (1/2/3/4)

2.3±0.62

Cormach-Lehane score (1/2/3/4)

2.1±0.61

Data are given as mean±standard deviation (SD) or number of patients (% incidence).

Table 2. Accuracy rate and time taken to assess the CTM and VAS difficulty scores

Palpation US (n=110) (n=110)

p

Accuracy rate (%)

50 (45.5)

82 (74.5)

<0.05

54.1±10.4

29±5.03

<0.001

5.1±1.1

3.32±0.9

<0.001

Time taken to assess the CTM (seconds) VAS difficulty score (0–10 cm)

CTM: Cricothyroid membrane; VAS: Visual Analog Scale; US: Ultrasound. Data are presented as mean±standard deviation (SD) or number of the patients (% percentage).

Table 3. Measurement of CTM localization by palpation, US, and CT

Measurement Measurement Measurement by palpation by US by CT (mm) (mm) (mm) (n=110) (n=110) (n=110)

Mean±SD 6.49±1.2 4.04±0.7 3.71±0.47 Median (min-max)

7 (1.11–8.4)

4.6 (0.56–5.2)

3.6 (0.35–4.6)

CTM: Cricothyroid membrane; US: Ultrasound; CT: Computed tomography; SD: Standard deviation. Data are presented as mean±standard deviation (SD) or median (min-max).

The distance between Points A and B was calculated as 6.49±1.2 mm by palpation and 4.04±0.7 mm by US, while this distance was calculated as 3.71±0.47 mm by CT (Table 3). 358

The mean time for the assessment of CTM by palpation and US was 54.2±10.4 seconds (95% CI 52.2–56.1 seconds) and 29.0±5.03 seconds (95% CI 28.0–29.9 seconds), respectively, p<0.001 (Table 2). The duration for detecting the localization of the CTM by palpation was significantly longer than with US. The VAS scores for palpation and US difficulty were 5.13±1.1 and 3.32±0.9 cm, respectively. Thus, to find the CTM by palpation is significantly more difficult than with US (p<0.001) (Table 2). Binary logistic regression was later performed for the following factors: gender, BMI, the thyromental distance, sternomental distance, neck circumference, mouth opening, the Mallampati classification, and the Cormach–Lehane scores. Of these, while an increased neck circumference (p=0.010; OR, 2.099; 95% CI, 1.193–3.693) and thyromental distance (p=0.004; OR, 0.076; 95% CI, 0.013–0.443) were found to be independent risk factors for the success rates of determining CTM by palpation, BMI was the independent risk factor for the success rates of determining CTM by US (p<0.002; OR, 0.369; 95% CI, 0.195–0. 701).

DISCUSSION This study was conceptualized to determine the success rates of palpation and US to localize CTM, and to compare the results with CT, which is the most commonly used radiological technique in the upper airway evaluation. According to our study results, an accurate localization of CTM was more unsuccessful when conventional palpation (45.4%) was used than US (74.5%), and US has improved the success rates. Similar results were reported in the literature in previous studies.[14,15] Interestingly, the palpation method has only been compared to US, which is also inadequate in defining CTM borders. CT is expected to be more precise than the US and palpation method, because CT imaging is considered to be an omnipresent feature reflecting the precise anatomy of CTM. [10] Therefore, this study compares and validates the palpation and US method against the commonly used technique, i.e., CT scan, for the first time to the best of our knowledge. According to the results of our study, the average distance between Points A and B was measured as 6.49±1.2 by palpation and 4.04±0.7 by US (millimeters ± SD). The study of Aslani et al.[16] indicated that CTM should be within 5 mm of the midpoint. Since CTM is a very small, errors >5 mm might cause major complications, such as a cricothyroidotomy failure, cricoid/thyroid cartilage puncture, or soft tissue damage. Although the measurements taken by US are within these ranges, palpation results exceed this cut-off point. The Bland–Altman analysis of our results indicate that the US results are closer to CT than palpation, which indicates that the CTM localization can be done more precisely by US. Ulus Travma Acil Cerrahi Derg, July 2019, Vol. 25, No. 4


Altun et al. Role of US in determining the CTM localization in the predicted difficult airway

Despite advanced airway management options, cricothyroidotomy is considered to be the last but crucial method for an emergency airway access in difficult airway management. Traditional methods to identify the surface landmarks of CTM rely on inspection and palpation, but the CTM localization is often difficult or impossible with these methods.[5,17] Hence, clinicians are often mistaken, which may lead to serious complications that might cause prolonging of the hypoxia time or chronic airway problems. In our study, a statistically significant relation between an increased neck circumference and thyromental distance was found with the failure of CTM palpation. In the study of Aslani et al.,[16] a statistically significant relation between the palpation failure and weight, BMI, and neck circumference was observed. Although our results are consistent with the literature, they do not confirm the correlation between BMI and the male gender with palpation failure, which should be re-evaluated with a higher number of subjects. US has been shown as a reliable, noninvasive method in the evaluation of the airway and determination of the CTM, and several studies have investigated the accuracy of the USguided localization of the CTM over classic landmark techniques.[6,14,15,18–20] The ease of US use is significantly correlated more strongly with a higher BMI, the male gender, an increased neck circumference, thyro-mental distance, and sterno-mental distance. However, the multivariate analysis results show that only a higher BMI reached statistical significance. You-Ten et al.[6] reported that a high BMI (defined as obesity, BMI ≥30 kg.m2) was significantly correlated with an increased inaccuracy in CTM locating. Cricothyroidotomy is performed as an emergency method. This increases the significance of the duration of the procedure greatly, which is directly proportional to the hypoxia period. Our results show that time consumed to localize CTM by palpation is significantly longer than in US. Of note, our time for the US measurement only accounts for the time when the probe is placed on the anterior neck. However, the transfer of the machine to the operating room and preparation may also cause the loss of time in a critical situation. As presented in previous studies according to the DAS, the recommended mean time for the assessment of CTM was 40 seconds or less for airway rescue.[14,21,22] To achieve such a critical timing, DAS guidelines also recommend that the identification of trachea and CTM should be done during the preoperative evaluation, and the examination of the patient should be performed with US if the landmarks are not clear.[4] The most important limitation to our study is that the investigator performed palpation and US evaluation under elective conditions, when the patient has already been intubated. This condition might have positively affected the localization time and lower the VAS scores. On the other hand, performing this study in real emergency scenarios would not be ethical. Ulus Travma Acil Cerrahi Derg, July 2019, Vol. 25, No. 4

In emergency conditions, US may lengthen the time taken to identify the CTM and to complete the procedure. The other limitation of the study is that, although our staff anesthesiologists received a training for US evaluation for airway during their residency, this training has not been evaluated. Although a revision for the study was completed prior to patient inclusion, an experience in ultrasonographic assessment is limited. This condition might negatively alter our localization time scores and might cause higher VAS scores. However, the fact that US is related to consistent evaluation times and a better accuracy, even in limited experience, is important.

Conclusion In conclusion, our study differs from the aforementioned studies, as the US method has not been validated against the commonly used technique, which is a CT scan, to determine the precision of identifying the midpoint of CTM. Our results indicated that the CTM localization is more accurate and easier when using US than by palpation; however, obesity might aggressively affect the US airway evaluation. Furthermore, the results gathered with US are in close range with CT scan. Lastly, to increase the success rate and decrease the complication rate while performing cricothyroidotomy, the US use may prove to be an important method, but further research on this clinical application should be performed. Institutional Ethics Committee Approval: 2016/84 Government Ethics Committee Chair: Prof. Dr. A. Yağız Üresin. Funding: This research was carried out without funding. Conflict of interest: None declared.

REFERENCES 1. Cook TM, Woodall N, Frerk C; Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia. Br J Anaesth 2011;106:617– 31. 2. Langvad S, Hyldmo PK, Nakstad AR, Vist GE, Sandberg M. Emergency cricothyrotomy-a systematic review. Scand J Trauma Resusc Emerg Med 2013;21:43. 3. Erlandson MJ, Clinton JE, Ruiz E, Cohen J. Cricothyrotomy in the emergency department revisited. J Emerg Med 1989;7:115–8. 4. Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth 2015;115:827–48. 5. Lamb A, Zhang J, Hung O, Flemming B, Mullen T, Bissell MB, et al. Accuracy of identifying the cricothyroid membrane by anesthesia trainees and staff in a Canadian institution. Can J Anaesth 2015;62:495–503. 6. You-Ten KE, Desai D, Postonogova T, Siddiqui N. Accuracy of conventional digital palpation and ultrasound of the cricothyroid membrane in obese women in labour. Anaesthesia 2015;70:1230–4. 7. Siddiqui N, Arzola C, Friedman Z, Guerina L, You-Ten KE. Ultra-

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Altun et al. Role of US in determining the CTM localization in the predicted difficult airway sound Improves Cricothyrotomy Success in Cadavers with Poorly Defined Neck Anatomy: A Randomized Control Trial. Anesthesiology 2015;123:1033–41. 8. Curtis K, Ahern M, Dawson M, Mallin M. Ultrasound-guided, Bougieassisted cricothyroidotomy: a description of a novel technique in cadaveric models. Acad Emerg Med 2012;19:876–9.

method in the morbidly obese. Br J Anaesth 2015;114:1003–4. 16. Aslani A, Ng SC, Hurley M, McCarthy KF, McNicholas M, McCaul CL. Accuracy of identification of the cricothyroid membrane in female subjects using palpation: an observational study. Anesth Analg 2012;114:987–92.

9. Tsui B, Ip V, Walji A. Airway sonography in live models and cadavers. J Ultrasound Med 2013;32:1049–58.

17. Elliott DS, Baker PA, Scott MR, Birch CW, Thompson JM. Accuracy of surface landmark identification for cannula cricothyroidotomy. Anaesthesia 2010;65:889–94.

10. Nutbeam T, Clarke R, Luff T, Enki D, Gay D. The height of the cricothyroid membrane on computed tomography scans in trauma patients. Anaesthesia 2017;72:987–92.

18. Yıldız G, Göksu E, Şenfer A, Kaplan A. Comparison of ultrasonography and surface landmarks in detecting the localization for cricothyroidotomy. Am J Emerg Med 2016;34:254–6.

11. Mallampati SR, Gatt SP, Gugino LD, Desai SP, Waraksa B, Freiberger D, et al. A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J 1985;32:429–34.

19. Siddiqui N, Yu E, Boulis S, You-Ten KE. Ultrasound Is Superior to Palpation in Identifying the CricothyroidMembrane in Subjects with Poorly Defined Neck Landmarks: A RandomizedClinical Trial. Anesthesiology 2018;129:1132–9.

12. Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics. Anaesthesia 1984;39:1105–11. 13. How can I decide the sample size for a study of agreement between two methods of measurement? Available at: https://www-users.york.ac.uk/ ~mb55/meas/sizemeth.htm. Accessed July 2, 2019.

20. You-Ten KE, Wong DT, Ye XY, Arzola C, Zand A, Siddiqui N. Practice of Ultrasound-Guided Palpation of Neck Landmarks Improves Accuracy of External Palpation of the Cricothyroid Membrane. Anesth Analg 2018;127:1377–82.

14. Nicholls SE, Sweeney TW, Ferre RM, Strout TD. Bedside sonography by emergency physicians for the rapid identification of landmarks relevant to cricothyrotomy. Am J Emerg Med 2008;26:852–6.

21. Dinsmore J, Heard AM, Green RJ. The use of ultrasound to guide timecritical cannula tracheotomy when anterior neck airway anatomy is unidentifiable. Eur J Anaesthesiol 2011;28:506–10.

15. Kristensen MS, Teoh WH, Rudolph SS, Tvede MF, Hesselfeldt R, Børglum J, et al. Structured approach to ultrasound-guided identification of the cricothyroid membrane: a randomized comparison with the palpation

22. Henderson JJ, Popat MT, Latto IP, Pearce AC; Difficult Airway Society. Difficult Airway Society guidelines for management of the unanticipated difficult intubation. Anaesthesia 2004;59:675–94.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Öngörülen zor havayolunda krikotiroit membran lokalizasyonunun belirlenmesinde ultrasonografinin rolü Dr. Demet Altun,1 Dr. Achmet Ali,1 Dr. Kemalettin Koltka,1 Dr. Mehmet Buget,1 Dr. Mehmet Çelik,2 Dr. Can Doruk,2 Dr. Ali Emre Çamcı1 1 2

İstanbul Üniversitesi İstanbul Tıp Fakültesi, Anesteziyoloji ve Reanimasyon Anabilim Dalı, İstanbul İstanbul Üniversitesi İstanbul Tıp Fakültesi, Kulak Burun Boğaz Anabilim Dalı, İstanbul

AMAÇ: Bu çalışmanın amacı, ultrason (US) ve elle muayene yöntemlerinin başarı oranlarını araştırmak ve bilgisayarlı tomografiye (BT) karşı US ile elle muayenenin kıyaslanarak krikotiroid membranın (KTM) tanımlamak. GEREÇ VE YÖNTEM: Çalışmaya 110 hasta alındı. Tiroit kartilajın çıkıntısından sternal çentiğin ortasına kadar düzlemde orta hat belirlendikten sonra, iki nokta arasındaki mesafe (milimetre) ölçüldü. A noktası-KTM’nin orta noktası ile B noktası-tiroit kartilajın inferiyor kısmı arasındaki mesafe (milimetre) US ve elle muayene ile tek bir araştırmacı tarafından işaretlenerek ölçüldü. Ayrıca A noktası ile B noktası arasındaki mesafe BT kullanılarak hesaplandı. US ve elle muayene ile KTM’in belirlenmesi için geçen süre ve VAS skoru kullanılarak her iki yöntemin kolaylığı kaydedildi. Ek olarak hastaların demografik ve morfometrik karakteristikleri not edildi. BULGULAR: Krikotiroit membran elle muayene ile 50 hastada (%45.5) ve US ile 82 (%74.5) hastada doğru olarak saptandı. Blant-Altman analizine göre US ile elle muayeneye göre daha iyi uyum gözlendi. KTM yerinin belirlenmesi için geçen süre US ile elle muayeneden daha kısa idi (p<0.001). VAS değerleri elle muayene ve US ile sırasıyla 5.13±1.1, 3.32±0.9 bulundu (p<0.001). Artan boyun kalınlığı ve tiromental mesafe elle muayene başarısını etkileyen risk faktörü olarak saptanırken US için risk faktörü olarak vücut kitle indeksi (VKİ) bulundu. TARTIŞMA: Krikotiroit membranın lokalizasyonu US ile elle muayeneden daha doğru ve kolay saptanmıştır. Ayrıca US ile bulunan sonuçlar BT’ye daha yakın bulunmuştur. Anahtar sözcükler: Havayolu yönetimi; krikotiroit kıkırdak; tiroit kıkırdak; ultrason görüntüleme. Ulus Travma Acil Cerrahi Derg 2019;25(4):355-360

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doi: 10.14744/tjtes.2019.65250

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ORIG I N A L A R T IC L E

Mapping and prediction of organ procurement in cases resulting in mortality due to traumatic injuries: A matched cohort analysis Özgur Albuz, M.D. Department of General Surgery, Keçiören Training and Research Hospital, Ankara-Turkey

ABSTRACT BACKGROUND: The prediction of posttraumatic potential organ donors is a complex process. The aim of this study is to evaluate the organ procurement process in trauma-related injuries and determine the medical markers in organ donors and posttraumatic mortal patients at the first level emergency, in emergency surgical service, and surgical intensive care departments. METHODS: In this retrospective study, after the approval of the ethics committee, the records of the patients in the emergency surgery unit, the operating room, and the organ donors in surgical intensive care unit between the years 2000 January–2011 December were examined. Patient demographics, distribution of donated organs, intubation area, transfer to the hospital, patient’s service, trauma type, injury mechanism, and severity of the injury were examined. Continuous variables were evaluated with independent samples by the Student’s t-test or Mann-Whitney U test and binary variables with the Pearson Chi-Square test. The patients who lost their lives and survived in the emergency department (ED) were compared with an age ratio of 1: 3. Final results were evaluated by multiple logistic regression. RESULTS: The patients with ≤90 mmHg systolic blood pressure (SBP) or penetrant serious injuries were more likely to be candidates for organ donation in ED, respectively; 68.2% vs. 15.2% [AOR: 4.59 (1.14, 18.40), p<0.031] and 63.6% vs. 37.9% (AOR: 6.25 [1.27–30.49] [p<0.024]). Patients with AIS head ≥3 and in-hospital blood replacement of 1500 cc or more, were more likely to be organ donors after ED: 54.5% vs. 97% (AOR: 0.074 [0.014 kan0.548], [p<0.01]) and 10% vs. 58.1% (AOR: 0.098 [0.016–0.591], p<0.01]). CONCLUSION: In terms of predictive traits for organ procurement, a SBP of ≤90 mmHg and presence of serious penetrant injuries were found to be more predictive for organ transplantation than other factors such as AIS Head ≥3 or 1500 cc or more replacement of blood and blood products. Keywords: Level I emergency department; organ procurement process; predictive factors; posttraumatic deceased donors.

INTRODUCTION A significant deficiency in the suitable organs for transplantation exists in the United States (US) nowadays.[1] Almost 91,000 cases of last stage organ failure are on the US organ transplantation waiting list.[2] The organ donation and transplantation society in the US maintains this list to ensure an effective change and better performance and quality. Organ transplantation still the only life-protective treatment

for a lot of cases with organ failure.[3] While the frequency of organ donation has increased slightly in recent years, the growing prevalence of those waiting for transplantable organs has also increased.[4] The General Accounting Office first recognized the need for accurate and reliable estimates of donor potential at the regional level in 1993. The development of an adequate measure is essential in determining the effectiveness of an OPO (organ procurement organization).[5]

Cite this article as: Albuz Ö. Mapping and prediction of organ procurement in cases resulting in mortality due to traumatic injuries: A matched cohort analysis. Ulus Travma Acil Cerrahi Derg 2019;25:361-368. Address for correspondence: Özgür Albuz, M.D. Keçiören Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, 06280 Ankara, Turkey Tel: +90 312 - 356 90 00 E-mail: oalbuz@gmail.com Ulus Travma Acil Cerrahi Derg 2019;25(4):361-368 DOI: 10.14744/tjtes.2019.77250 Submitted: 20.03.2019 Accepted: 27.03.2019 Online: 08.07.2019 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

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Albuz. Mapping and prediction of organ procurement in mortal traumatic cases

From the first stage to the last stage, the donation and transplantation process is complex. It starts with the confirmation and maintenance of potential donors. Next, physicians inform the family about the patient’s suspected brain death (BD), carry out tests to prove this diagnosis, and simultaneously notify the Organ Donation and Procurement Agency (CNCDO) to provide a potential donor.[6] Since the exclusion criteria for organ donation may vary from region to region, identification and referral of all potential organ donors to the local OPO for further evaluation is the main rule. Additionally, regulations of the medical services and centers state that all ventilator-dependent patients with severe brain injury must be referred to the local OPO before the termination of life-support measures. These steps must be done in collaboration with the intensive care unit (ICU), OPO personnel, and the transplant program staff.[7] The Board of Directors of the American College of Emergency Physicians (ACEP) adopted a policy that recognizes the requirement for organ and tissue donation and procurement, which highlights the key role emergency medicine (EM) can play in this process.[8] Several policy issues plague the field of transplantation, most of which revolve around how to allocate this scarce and lifesaving resource equitably. The main problem is access. Ethnic minority populations are affected disproportionately by endstage organ failure but often need to wait significantly longer than Caucasians to receive an organ.[9] Economic and gender inequality are also points of concern.[10] Allocation issues would be considerably less difficult if more suitable organs were available. Proposals to increase organ availability include improving procurement effectiveness of hospitals and OPOs, increasing the willingness of the public to donate, enforcing presumed consent legislation, and providing financial incentives.[11] In terms of the timing of organ procurement, unstable hemodynamic conditions most often characterize the timing between BD and the procurement of organs. These conditions must be expertly managed to maintain the viability and optimal condition of the organs.[12] The above-mentioned procedures along with timely hemodynamic management are the key to successful donor management. The primary purpose of the current study is to identify predictive factors of traumatic deceased patients who referred for a donation by the ED (emergency department), while the secondary purpose is to determine traumatic patient characteristics and perform mapping of the process of organ donation.

MATERIALS AND METHODS Material The conducted study is a single-center retrospective study of all patients admitted for organ procurement after trauma to Los Angeles County and University of Southern California (LAC–USC) Medical Center. 362

After institutional review board approval (10/31/2012), all consenting donors from 2000 January–2011 December were identified by the University of Southern California Medical Center Trauma, Surgical Critical Care, and Emergency Surgery registry. Between 2000 January–2011 December, 264 trauma patients were declared BD and they donated one or more organs. A total of 13 patients in this cohort study were excluded because relevant data for analysis could not be extracted from their medical charts.

Method The primary measure was the identification of systolic blood pressure lower than 90 mmHg at admission. Secondary measures were the identification of the need of more than 1500 cc hospital blood replacement products (major transfusion), field intubation, assisted ventilation, and an AIS Head greater than or equal to 3.

Collection of Data and Statistical Method The data examined included patient demographics (age, sex, race), organ procurement, field intubation, entry mode, admission site (ED, OR, ICU), mechanism of trauma, mechanism of injury, and injury severity and characteristics. Using the Pearson Chi-Square or Student’s t-tests, we performed bivariate analyses to compare characteristics of organ procurement and assess differences between in ED deceased cases and non-ED deceased cases, using a ratio of 1:3 matching for age. Logistic regression was utilized to determine the independent predictors of organ procurement after ED admission.

RESULTS Out of 264 patients that were examined in the study, the mean patient age was 31.78 years±15.68 years; 81.7% were male. The overall injury severity score was 31.18±12.19. The mean length of hospital stay from BD to organ procurement was 2.60±4.40 (0–40) days. The mean time of the initial vital signs time after admission was 1.13±2.88 (0–23) minutes. The assisted ventilation rate was 147 (58.6%) vs. 104 (41.4%). The highest field intubation was 64 (25.5%). Entry mode distributions EMS (Emergency Medical Services) with the ground were 216 (86.4%), EMS with airways were 25 (9.96%), cases transferred with family relatives were 6 (2.4%), and direct admissions were 3 (1.2%). When examining the trends of organ procurement distribution over time for ethnicity, the majority of organ procurement deceased cases were Hispanic (174 [69.3%]), followed by Caucasian (35 [13.9%]), Asians (19 [7.6%]), and African Americans (15 [6%]), and others (8 [3.2%]) (Table 1). The distribution of hospital phase rates in the trauma patients before organ procurement was 207 (82.5%) ICU, 28 (11.2%) ED, 9 (3.6%) OR, 4 (1.6%) ward, 3 (1.2%) (PICU-stepdown) others (Table 1). Injury characteristics of traumatic organ procurement cases are presented in Table 2; GCS (Glasgow Coma Scale) less than Ulus Travma Acil Cerrahi Derg, July 2019, Vol. 25, No. 4


Albuz. Mapping and prediction of organ procurement in mortal traumatic cases

Table 1. Demographic characteristics of posttraumatic deceased cases for organ procurement

Table 2. Injury characteristics of traumatic organ procurement cases

Characteristics

Characteristics

Age, mean±SD [range]

n=251 Percent 31.78±15.68 (3–88)

n

%

Injury mechanism

Age ≥55% (#)

27

10.8

Blunt

156

62.2

Male gender % (#)

205

81.7

Penetration

95

37.8

The mean time of the initial vital

1.13 min ± 2.88 min

Trauma mechanism

(0–23 min)

Gunshot

95

37.8

signs time after admission

Fall

41

16.3

Ethnicity

14

5.6

Hispanic

174

Road accident (MVA + pedestrian

White

35 13.9

– bike + motorcycle + motorbike)

91

36.2

Asians

19 7.6

Other

6

2.4

African Americans

15

Unknown

4 1.6

Other

8 3.2

69.3

6

Arrive way Ground/EMS

216

Air/EMS

25 9.96

86.4

Assault

ISS (mean±SD)

31.18±12.19

ISS ≥16

240

95.6

GCS ≤8%

225

89.6

RTS ≥6

220

87.7

Other (direct admit-

SYS ≤90 mmHg

47

18.7

transferred with

Head >2

233

92.8

family relatives)/EMS

9

3.60

Abdomen >2

22

8.8

Field Intubation

64

25.5

Chest >2

59

23.5

Assisted ventilation

147

58.6

Subarachnoid hemorrhage (SAH)

63

25.1

Intracranial hemorrhage (ICH)

14

5.6

Prior phase before organ procurement process Intensive care unit

207* 82.4*

Emergency department

28

11.1

Operative room

9

3.50

Ward

4 1.60

Others

3 1.20

EMS: Emergency Medical Services; SD: Standard deviation; Min: Minimum.

or equal to 8: 225 (89.2%) and SBP (systolic blood pressure) less than or equal to 90: 47 (18.9%). The injuries due to penetrating trauma were 95 (37.8%) and the injuries due to blunt trauma were 156 (62.2%). Detailed analysis of trauma distribution patterns consequently were gunshot: 95 (37.8%); pedestrian-bike accident: 50 (19.9%); fall: 41 (16.3%); motor vehicle accident: 34 (13.6%); assault: 14 (5.6%); motorcycle accident: 7 (2.8%); other: 6 (2.4%); or unknown: 4 (1.6%). In this cohort, subarachnoid hemorrhage (SAH) cases were 63 (25.1%) and intracerebral hemorrhage (ICH) were 14 (5.6%) (Table2). In the distribution of organ procurements for all patients dependent on traumatic mortality between 2000 January–2011 December, when examining the trends of organ procurement rate over time, we fund that the rates in 2001 (11.9%), 2004 (10.5%), and 2005 (11.2%) were found to be higher than for other years (Table 4) (Fig. 1). Ulus Travma Acil Cerrahi Derg, July 2019, Vol. 25, No. 4

ISS: Injury severity score; GCS: Glasgow coma scales; SYS: Systolic blood pressure; RTS: Revised Trauma Score; SD: Standard deviation.

Table 3. Distribution of organ procurements for all patients depending on traumatic mortality between 2000 to 2011 Procured organ

Number of procured organs

%

Kidney

199 27.5

Liver

172 23.8

Heart

133 18.4

Pancreas

106 14.6

Lung

52 7.2

Eye

21 2.9

Tissue

36

5

Intestine and other

5

0.7

The total number of procured organs for transplantation was 724. Procured organs distribution were found to be 199 kidneys (27.5%), 172 livers (23.8%), 133 hearts (18.4%), 106 pancreas (14.6%), 52 lungs (7.2%), 36 tissues (5 %), 21 eyes (2.9%), 5 intestines, and others (0.7%) (Table 3) (Fig. 2). The mean organs procured per donor were 2.9. 363


Albuz. Mapping and prediction of organ procurement in mortal traumatic cases

100

20

80

60

15 Count

Frequency

Years 2000.00 2001.00 2002.00 2003.00 2004.00 2005.00 2006.00 2007.00 2008.00 2009.00 2010.00 2011.00

Years

40

10 20 5

200

Count

Ti ss ue

cr e

as

r

s

th e

Pa n

O

ng Lu

ve r

y ne

Figure 3. The distribution of procured organs for organ transplantation each year.

an AIS Head ≥3 and replacement of hospital blood products of 1500 cc or more were significantly less likely to be candidates for the organ procurement process in the ED; 54.5% vs. 97%, (AOR: 0.074 [0.014–0.548] [p<0.01]) and 10% vs. 58.1%, (AOR: 0.098 [0.016–0.591] [p<0.01]), respectively. On the other hand, the penetrant injury was found significant as 63.6% vs. 37.9% (AOR: 6.25 [1.27–30.49] [p<0.024]) (Table 7).

150

100

50

DISCUSSION e su Ti s

as nc

re

er th

s

r

Pa

O

ng Lu

ve Li

rt

ey dn Ki

ea H

Ey

e

0

Procurement organs

Figure 2. The distribution of procured organs for organ transplantation between 2000 to 2011.

In terms of mapping of organ procurement, when subgroup analysis was performed; it was observed that the first-procured organ for every year was the kidney. As an exception, in 2005 the number of livers procured was equal to the number of kidneys (Table 4) (Fig. 3). The result of patient characteristics for a univariate cohort analysis on an age ratio of 1:3 between ED and non-ED cases were; ISS ≥16, SBP ≤90 mmHg, Head AIS ≥3, field intubation, and assisted ventilation were found significant among for prediction of the organ procurement candidates (Table 5). After 1:3 matching for age between overall mortality in ED and overall mortality in non-ED, adjusting for differences between covariates, patients with systolic blood pressure lower than 90 mm Hg in ED were more likely to be candidates for the organ procurement process as 68.2% vs. 15.2%, (AOR: 4.59 [1.14, 18.40] p<0.031) (Table 6). In contrast, patients with 364

Li

H

Figure 1. Total procurement frequency for organ transplantation between 2000 and 2011.

Ki d

rt

0 Ey e

Years

ea

20

00 . 20 00 01 . 20 00 02 . 20 00 03 20 .00 04 20 .00 05 . 20 00 06 . 20 00 07 . 20 00 08 20 .00 09 . 20 00 10 . 20 00 11 .0 0

0

As of the time of the second world war, organ transplantation has been developing and increasing its effectiveness.[1,13] Organs can be procured from living donors and also from deceased donors. Although the rate is slow, the number of living donors has risen consistently but is almost exclusively restricted to the procurement of kidneys.[14,15] Only a small proportion of all potential donors can donate. We know this because of the special donation conditions for deceased individuals. The availability of the donor is based on the relationship between the nature of the critical injury and the illness trajectory subsequent to it.[16] The course of organ procurement and protection of optimization is a complex effort. By its nature, organ procurement for organ donation has greater complexity than most other medical procedures. Organ procurement activation requires significant organizational, clinical, ethical, and social responsibilities. An institutional and individual sustainable encouragement is the cornerstone that identifies the possible potential organ donors and supplies increased organ donor candidates for acute care processes. [17] In light of this reality, this process needs enough time for successful procurement activation. Further, especially in the ED, the entire process can develop very quickly for the patient, patient family, and medical staff. Unfortunately, deaths in the ED are usually sudden, unexpected, and traumatic and Ulus Travma Acil Cerrahi Derg, July 2019, Vol. 25, No. 4


Albuz. Mapping and prediction of organ procurement in mortal traumatic cases

Table 4. Total procurement organ frequency and distribution from 2000 to 2011

2000 2001 2002 2003 2004

2005 2006 2007 2008 2009 2010 2011 n

Kidney 12* 21* 18* 12* 19* 21* 15* 15* 14* 16* 17* 19* 199 Liver

11 19

14 11 18

21* 15 12 8 14 13 16 172

Heart

6 18 13 10 15

14 10 8 9 12 8 10 133

Pancreas

7 16 11 8 11

12 10 7 4 8 5 7 106

Lung

3 7 4 3 8

4 3 2 4 5 4 5 52

Eye

2 1 2 1 1

5 2 3 2 2 0 0 21

Intestine and other 2 3 0 0 0

0 0 0 0 0 0 0 5

Tissue

0 1 0 4 4

4 2 3 4 8 4 2 36

Toplam, n (%)

43

86 (11.9) *

62

49

76 (10.5)

81 (11.2)* 57 50 45 63 51 59 724

Table 5. Patient characteristics of 1:3 matched cohort analysis for age between ED and non-ED cases 1:3 Matched cohort analysis (n=88) with univariate analysis Age, mean±SD (range)

Organ procurement process depending on ED phase mortality (n=22)

Organ procurement process depending on Non-ED phase mortality (n=66)

p

31.13±17.78 (16–79)

31.21±16.45 (16–78)

0.985

30.96±16.42 (16–75)

Age ≥55%, n (%)

12 (13.6)

3 (13.6)

8 (12.1)

0.85

30.21±12.73 (1–75)

29.40±18.30 (1–75)

30.65±10.89 (10–75)

0.765

ISS ≥16, n (%)

83/88 (94.3)

18/22 (81.8)

65/66 (98.5)

<0.013

GCS ≤8%, n (%)

81/87 (93.1)

22 (100)

59 (90.8)

0.33

RTS ≤6, n (%)

ISS, mean±SD (range)

79/85 (92.9)

22 (100)

57 (90.5)

0.33

SYS ≤90 mmHg, n (%)

25 (28.4)

15 (68.2)

10 (15.2)

<0.001

Male gender, n (%)

80 (90.9)

20 (90.9)

60 (90.9)

0.576

Head AIS ≥3, n (%)

76 (86.4)

12 (54.5)

64 (97.0)

<0.001

Chest AIS ≥3, n (%)

22 (25)

8 (36.4)

14 (21.2)

0.16

Abdomen AIS ≥3, n (%)

6 (6.8)

2 (9.1)

4 (6.1)

0.64

Field intubation, n (%)

33 (39.8)

14 (63.6)

19 (31.1)

<0.008

Assisted ventilation, n (%)

59 (67.0)

19 (86.4)

40 (60.6)

<0.026

≥1500 cc, n (%)

38 (46.3)

2 (10)

33 (58.1)

<0.001

Penetrant injury, n (%)

39 (44.3)

14 (63.6)

25 (37.9)

<0.035

Hospital blood product

AIS: Abbreviated injury score; GCS: Glasgow coma scales; ISS: Injury severity score; SYS: Systolic blood pressure; ED: Emergency department; SD: Standard deviation.

Table 6. Results of multiple logistic regression and the prediction of patients whose organs were procured for organ transplantation Effect of systolic blood All pressure over deceased patients case rates from ED (n=88) SYS ≤90 mmHg

28.4% (25)

Organ procurement process depend on ED phase mortality (n=22) 68.2% (15/22)

Organ procurement p value process depend on Non-ED phase mortality (n=66) 15.2% (10/66)

<0.001

Adjusted OR (95% CI)

Adjusted p value

4.59 [1.14–18.40]

<0.031

Logistic regression performed; adjusting for differences in ISS >16, GCS ≤8, head ≥3, systolic blood pressure ≤90 mmHg, field intubation, assisted ventilation, hospital blood replacement ≥1500 cc, penetrant injury. ISS: Injury severity score; SYS: Systolic blood pressure; ED: Emergency department; OR: Odds ratio.

usually involve young patients. Under these conditions, the coordination between the emergency physician and OPO can Ulus Travma Acil Cerrahi Derg, July 2019, Vol. 25, No. 4

convert a life lost at the ED into a source of light for candidates waiting for transplantation.[18] The Board of Directors 365


Albuz. Mapping and prediction of organ procurement in mortal traumatic cases

Table 7. The results of the logistic regression for independent predictors of organ procurement and the dependent process Secondary outcomes All patients (n=82) AIS head ≥3

Organ procurement process depend on ED phase mortality (n=22)

Organ procurement p value process depend on Non-ED phase mortality (n=66)

Adjusted OR (95% CI)

Adjusted p value

76

54.5% (12/22)

97.0% (64/66)

0.001

0.074 (0.014–0.548)

<0.01

38

10% (2/20)

58.1% (36/62)

0.001

0.098 (0.016–0.591)

0.012

39 (44.3%)

14 (63.6%)

25 (37.9%)

<0.035

6.25 (1.27–30.49)

0.024

Hospital blood products ≥1500 cc Penetrant injury

*

Logistic regression performed; adjusting for differences in ISS >16, GCS ≤8, AIS Head ≥3, systolic blood pressure ≤90 mmHg, field intubation, assisted ventilation, hospital blood replacement ≥1500 cc, penetrant injury. ED: Emergency department; AIS: Abbreviated injury score; OR: Odds ratio.

of the ACEP has declared a policy that recognizes the requirements for organ and tissue donation and procurement, which highlights the role the EM can play in this process.[19] In 1998, Olsen and colleagues had underlined that the procurement of organs from deceased cases in the ED seldom takes place in the ED.[20] Additionally, if the right timing for the patient consent is taken into consideration along with the maximization of organ donation and transplantation, a sufficient explanation about the process should be provided to the family members who will decide the organ procurement instead of the post-traumatic unconscious patient. The success of such a complex process requires a highly specialized critical care staff.[7] The first 24 hours for a patient who is received in the ICU due to major trauma are important in the success of the organ procurement process. The reason for the early prediction of a donor for trauma patients is important to achieve successful donation rates among patients referred from the ED or ICU on the first day. Unstable hemodynamic conditions most often characterize the process between BD and the procurement of organs.[7] In terms of keeping the viability and optimal condition of the organs, these conditions must be addressed and managed.[12] As a result, punctual hemodynamic management is the main principle of successful donor management.[7] While our results suggest that a lower SBP (≤90 mmHg) is a significant distinctive predictor of mortality among traumatic deceased patients who are referred from the ED for donation, we also suggested that a higher AIS for head (≥3) is also a distinctive predictor of mortality among traumatic deceased patients referred within the first 24 hours for donation. We believe that this prediction is important in the need for available organs in terms of providing enough time. In terms of the cadaver-related organ transplant, male donors cater to the majority of transplanted organs,[1] which is dependent on the increased incidence of traumatic death among males than females, which in turn has led to a greater number of potential male organs for transplantation.[21] When examining the trends of cadaveric organ donation in terms of gender (Table 2), there was no difference in the literature for our 12-year study period 366

(male 81.7% vs. female 18.3%). The racial differences in organ donation of our study, when compared with the racial differences in other studies, were lower in terms of organ donation among deceased cases. Additionally, a lower rate of acceptance of donated organs was found between African Americans and Asians referred for organ donation (Hispanic 69.3% vs. Caucasian 13.9% vs. Asian 7.6% vs. African American 6% vs. 3.2% others) (Table 2). It is clear that much work remains to be done in overcoming social, economic, and racial obstructions to transplantation.[22–26] The lower rate of organ donation for African Americans and for Asians may depend on a number of factors, including increased rates of medical comorbidity and a customary general mistrust of the medical establishment.[25,27–29] According to data from the Organ Purchasing and Transport Network in 2017, 5,800 people died while waiting for organs. [30] The most effective and feasible treatment option for those with end-stage organ failure is organ transplantation. Patients being females, Caucasians, and patients with higher education and higher income levels were determined as positive predictions/correlations for organ donation.[31–33] For this reason, it is very important to convince the family by putting up the patients as a donor candidate after trauma. In the triage of traumatic cases to detect candidates for the organ procurement process, the below values of SBP greater than 90 mmHg and penetrative traumatic injuries to the victim may be the cornerstone for resolving this issue (Table 6). Furthermore, if systolic pressure is not lower than 90 mmHg, the factors of AIS Head ≥3 and1500 cc and more replacement of blood products may play a role (Table 7). In terms of timing of salvageable organs and consent for organ donation, the process of organ procurement activation must be done carefully under the guidance of trauma severity and other predictive markers.

Conclusion In the ED, the detection of potential organ donors is dependent on an increased likelihood of successful prediction of mortality. Conversely, there is limited time for the organ proUlus Travma Acil Cerrahi Derg, July 2019, Vol. 25, No. 4


Albuz. Mapping and prediction of organ procurement in mortal traumatic cases

curement process. While predicting potential organ donors from the ED, the detection of blood pressure lower than systolic 90 mmHg or presence of penetrant injuries may be significant. Additionally, both the AIS Head score ≥3 and\or given 1500 cc or more blood replacements may be helpful to detect candidates for the organ procurement process after the ED phase. Further prospective and multi-center studies will be beneficial to improve these predictive markers for detection of the organ procurement candidates after injury.

Acknowledgment I want to thank Prof. Dr. Demetrios Demetriades for supporting the submission of this manuscript. Additionally, I am honored that I got the opportunity to work as a research fellow at The University of Southern California Trauma and Surgical Critical Care under the management Prof. Dr. Demetrios Demetriades, between November 2011 and November 2012. Conflict of interest: None declared.

REFERENCES 1. Organ Procurement and Transplantation Network Data. Available at: https://optn.transplant.hrsa.gov/. Accessed July 4, 2019. 2. United Network for Organ Sharing. Current US waiting list. Available at: http:// www.unos.org. Accessed February 5, 2006. 3. Tuttle-Newhall JE, Krishnan SM, Levy MF, McBride V, Orlowski JP, Sung RS. Organ donation and utilization in the United States: 19982007. Am J Transplant 2009;9:879−93. 4. United States Health Resources and Services Administration. 2007 Annual Report of the U.S. Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients: Transplant Data 1997–2006. Rockville, MD: U.S. Dept. of Health and Human Services, 2007. 5. US General Accounting Office. Organ Transplants: Increased Effort Needed to Boost Supply and Ensure Equitable Distribution of Organs. Washington, DC: US General Accounting Office; 1993. 6. Moraes EL, Silva LB, Moraes TC, Paixão NC, Izumi NM, Guarino Ade J. The profile of potential organ and tissue donors. Rev Lat Am Enfermagem 2009;17:716−20. 7. O’Connor KJ, Wood KE, Lord K. Intensive management of organ donors to maximize transplantation. Crit Care Nurse 2006;26:94−100. 8. American College of Emergency Physicians.Emergency medicine’s role in organ and tissue donation. American College of Emergency Physicians. Ann Emerg Med 1996;28:384. 9. Callender CO, Hall LE, Yeager CL, Barber JB Jr, Dunston GM, PinnWiggins VW. Organ donation and blacks. A critical frontier. N Engl J Med 1991;325:442−4. 10. Miller JE. A study of factors affecting organ donation: compensation, financial incentives,and gender. J Transpl Coordination 1992;2:140−6. 11. DeJong W, Drachman J, Gortmaker S, Beasley C, Evanisko M. Options for increasing organ donation: the potential role of financial incentives,standardized hospital procedures, and public education to promote family discussion. Milbank Q 1995;73:463−79.

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12. Nygaard CE, Townsend RN, Diamond DL. Organ donor management and organ outcome: a 6-year review from a Level I trauma center. J Trauma 1990;30:728−32. 13. Auquier P, Reviron D, Erin CA, Sari I, Manuel C, Mercier P. Cadaver kidney transplantation: ethics and consent. Eur J Epidemiol 1995;11:495–9. 14. British Medical Association. Organ donation in the 21st century: time for a consolidated approach. London: BMA; 2000. 15. UK Transplant, Statistics and Audit Directorate. Transplant activity in the UK: 2007–2008. Bristol: UK Transplant; 2008. 16. Rithalia A, McDaid C, Suekarran S, Norman G, Myers L, Sowden A. A systematic review of presumed consent systems for deceased organ donation. Health Technol Assess 2009;13:1−95. 17. DuBose J, Salim A. Aggressive organ donor management protocol. J Intensive Care Med 2008;23:367−75. 18. Ergin M, Karaman L, Demircan A, Dalgiç A. Potential organ donor concept is developing in emergency departments: Gazi University Hospital experience. Transplant Proc 2008 ;40:39−41. 19. Emergency medicine’s role in organ and tissue donation. American College of Emergency Physicians. Ann Emerg Med 1996;28:384. 20. Rivers EP, Buse SM, Bivins BA, Horst HM. Organ and tissue procurement in the acute care setting: principles and practice – Part 1. Ann Emerg Med.1990;19:78−85. 21. Sauaia A, Moore FA, Moore EE, Moser KS, Brennan R, Read RA, et al. Epidemiology of trauma deaths: a reassessment. J Trauma 1995;38:185−93. 22. Churak JM. Racial and ethnic disparities in renal transplantation. J Natl Med Assoc 2005;97:153−60. 23. Gaylin DS, Held PJ, Port FK, Hunsicker LG, Wolfe RA, Kahan BD, et al. The impact of comorbid and sociodemographic factors on access to renal transplantation. JAMA 1993;269:603−8. 24. Stolzmann KL, Bautista LE, Gangnon RE, McElroy JA, Becker BN, Remington PL. Trends in kidney transplantation rates and disparities. J Natl Med Assoc 2007;99:923−32. 25. Alexander GC, Sehgal AR. Barriers to cadaveric renal transplantation among blacks, women, and the poor. JAMA 1998;280:1148−52. 26. Callender CO, Miles PV. Obstacles to organ donation in ethnic minorities. Pediatr Transplant 2001;5:383−5. 27. Lunsford SL, Simpson KS, Chavin KD, Menching KJ, Miles LG, Shilling LM, et al. Racial disparities in living kidney donation: is there a lack of willing donors or an excess of medically unsuitable candidates? Transplantation 2006;82:876−81. 28. Dodd-McCue D, Tartaglia A. African American consent and nonconsent cases: are there significant differences? Prog Transplant 2007;17:215−9. 29. Kurz RS, Scharff DP, Terry T, Alexander S, Waterman A. Factors influencing organ donation decisions by African Americans: a review of the literature. Med Care Res Rev 2007;64:475−517. 30. Wynn JJ, Alexander CE. Increasing organ donation and transplantation: the U.S. experience over the past decade. First published: Jan 1,2019. 31. Siminoff LA, Burant CJ, Ibrahim SA. Racial disparities in preferences and perceptions regarding organ donation. J Gen Intern Med 2006;21:995−1000. 32. Robinson DH, Klammer SM, Perryman JP, Thompson NJ, Arriola KR. Understanding African American’s religious beliefs and organ donation intentions. J Relig Health 2014;53:1857−72. 33. Quick BL, LaVoie NR, Reynolds-Tylus T, Bosch D, Morgan SE. Does Donor Status, Race, and Biological Sex Predict Organ Donor Registration Barriers? J Natl Med Assoc 108:140−6.

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Albuz. Mapping and prediction of organ procurement in mortal traumatic cases

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Travmatik yaralanmalara bağlı mortaliteyle sonuçlanan durumlarda organ alımlarının haritalanması ve tahmini: Eşleşmiş kohort analizi Dr. Özgur Albuz Keçiören Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, Ankara

AMAÇ: Travma sonrası potansiyel organ bağışçıların öngörüsü karmaşık bir süreçtir. Bu çalışmadaki amaç düzey I acil cerrahi, travma ve cerrahi yoğun bakım merkezlerinde on sene boyunca travmaya bağlı yaralanmalardaki mortal seyreden hastalardaki organ tedariği sürecini değerlendirerek travma sonrası mortal sonuçlanan hastalardaki organ bağışındaki tıbbi belirteçleri ortaya koymaktır. GEREÇ VE YÖNTEM: Geriye dönük olarak planlanan bu çalışmada etik kurul onayını takiben, acil cerrahi ünitesinde, ameliyathanede ve cerrahi yoğun bakımda organ bağışçısı olan hastaların 2000–2011 yılları arasındaki kayıtları incelendi. Hasta demografileri, bağışlanan organların dağılımları, entübasyon sahası, hastaneye nakil şekli ile hasta yakınlarının organ bağışını kabulleri esnasında hastanın bulunduğu servis, travma türü, yaralanma mekanizmasıyla şiddetleri incelendi. Sürekli değişkenler bağımsız gruplarda student t-test veya Mann-Whitney U-testiyle, ikili değişkenler Pearson ki-kare testiyle değerlendirildi. Acil serviste (AS) hayatını kaybeden ve kaybetmeyen olgular yaş bakımından 1: 3 eşleştirmeyle kıyaslandı. Sonuçlar çoklu lojistik regresyonla değerlendirildi. BULGULAR: Sistolik kan basıncı (SKB) 90 mmHg’nin altındaki hastalarla, penetran travma olguları AS’ye organ bağışı adayı olma olasılıkları çok daha yüksektir. Sırasıyla (%68.2 ve %15.2, AOR: 4.59 [1.14, 18.40] [p<0.031]) ve %63.6 ve %37.9 (AOR: 6.25 [1.27–30.49] [p<0.024]). Beyin travması açısından AIS ≥3 olmasının ve 1500 cc veya daha fazla hastane kan ürünleri replasmanı yapılan olgularda AS sonrası organ bağışçısı olma olasılıkları daha yüksektir (%54.5 ve %97, AOR: 0.074 [0.014–0.548] [p<0.01]) ve (%10 ve %58.1, AOR: 0.098 [0.016-0.591], [p<0.01]). TARTIŞMA: Travma sonrası potansiyel organ vericileri belirlemede acil servise kabulde SKB’nin 90 mmHg altında olması ve ciddi penetran hasarlanmalar, beyin travması hasar skoru (AIS ≥3) ve 1500 cc üzeri kan ve kan ürünü replasmanlarına göre potansiyel donörlerin belirlenmesinde daha öngördürücüdür. Anahtar sözcükler: Düzey I acil servis; organ tedarik süreci; öngörücü faktörler; travma sonrası ölen organ bağışçısı. Ulus Travma Acil Cerrahi Derg 2019;25(4):361-368

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doi: 10.14744/tjtes.2019.77250

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ORIG I N A L A R T IC L E

Comparison of ultrasound and physical examination with computerized tomography in patients with blunt abdominal trauma Azad Hekimoğlu, M.D.,1 Onur Ergun, M.D.,1 Seda Özkan, M.D.,2 Engin Deniz Arslan, M.D.,2 Baki Hekimoğlu, M.D.1 1

Department of Radiology, Dışkapı Yıldırım Beyazıt Training and Research Hospital, Ankara-Turkey

2

Department of Emergency Medicine, Dışkapı Yıldırım Beyazıt Training and Research Hospital, Ankara-Turkey

ABSTRACT BACKGROUND: In cases of blunt abdominal trauma, the abdomen is the third most affected region. Computerized tomography (CT) is the gold standard for the evaluation of these patients. However, considering its damaging effects and high cost, it may not be proper to refer every patient applying to the emergency unit for a CT examination. In this study, our objective was to compare the accuracy of ultrasonography (US) and physical examination in blunt abdominal trauma patients to the gold standard CT in order to prevent unnecessary CT examinations. METHODS: In this retrospective study, the files and images of 2248 patients, who applied to the emergency department of our hospital were screened. A total of 535 adult patients who underwent CT scanning after the ultrasonographic and physical examinations were included in the study. The findings of the US and physical examinations, the intraabdominal free fluid, and organ lacerations were compared to the results of CT. The compatibility, sensitivity, specificity, positive estimated value, and the negative estimated value of the obtained data were analyzed with statistical methods. RESULTS: The sensitivity of US in the demonstration of the intraabdominal free fluid was comparable with the sensitivity of CT in the patients with blunt abdominal trauma (p=0.302). The sensitivity and specificity of US was 49.6% and 99.3% respectively in the determination of the intraabdominal organ injuries. The sensitivity and specificity of the physical examination was 59% and 87% respectively in the determination of the free fluid and organ injury as compared to CT. Although the sensitivity and specificity of the physical examination were high separately in the organ injuries according to the statistical calculations, they seemed not to have had a statistically significant predictive value (p<0.001). CONCLUSION: Even though US is a reliable method for the determination of the intraabdominal fluid, US and physical examination are not reliable in the determination of the organ injuries as compared to CT. Keywords: Abdomen; physical examination; tomography; trauma; ultrasonography.

INTRODUCTION Trauma is currently the fourth most common cause of mortality in developed countries[1] and is the most common cause of mortality in the first four decades of life.[2] Fifty percent of the deaths below the age of 14 years, 80% of the deaths between 15 and 25 years of age and 65% of the deaths between

25 and 40 years of age are caused by trauma.[3] Abdominal traumas are the third most common cause of trauma-related deaths.[4] Traditionally, abdominal traumas are classified into two groups, penetrating and blunt abdominal traumas. In most cases, penetrating traumas can be easily diagnosed but blunt traumas are usually overlooked since the clinical findings are less prominent.[5] Death due to abdominal trauma

Cite this article as: Hekimoğlu A, Ergun O, Özkan S, Arslan ED, Hekimoğlu B. Comparison of ultrasound and physical examination with computerized tomography in patients with blunt abdominal trauma. Ulus Travma Acil Cerrahi Derg 2019;25:369-377. Address for correspondence: Azad Hekimoğlu, M.D. Dışkapı Yıldırım Beyazıt Eğitim ve Araştırma Hastanesi, Radyoloji Kliniği, 06100 Ankara, Turkey Tel: +90 312 - 596 26 18 E-mail: azadhekimoglu@gmail.com Ulus Travma Acil Cerrahi Derg 2019;25(4):369-377 DOI: 10.5505/tjtes.2018.88288 Submitted: 05.04.2018 Accepted: 08.11.2018 Online: 08.07.2019 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

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Hekimoğlu et al. Comparison of US and physical examination with gold standard CT in patients with blunt abdominal trauma

may be prevented if timely diagnosed.[6] Isolated blunt abdominal trauma constitutes 5% of the mortality due to the trauma and the blunt abdominal trauma contributes to 15% of the mortality due to the trauma in polytraumatic injuries.[7] Regarding the diagnosis, classification, and approach to the trauma patient, computerized tomography (CT) is very useful. [8] It was reported that patients with normal abdominal CT imaging do not need additional treatment.[9] In short, CT is the gold standard for the evaluation of the abdominal traumas. [10–14] The sensitivity increases to approximately 100% in the repeated CT scans while the specificity also increases to 86%.[15] However, considering its damaging effects and high cost, it may not be proper to refer every patient applying to the emergency unit for a CT examination. In this study, our objective was to compare the accuracy of ultrasonography (US) and physical examination in blunt abdominal trauma patients to the gold standard CT in order to prevent unnecessary CT examinations.

MATERIALS AND METHODS In this retrospective study, the files and images of 2248 patients, who applied to the emergency department of our hospital between January 2015 and March 2017 were screened. A total of 535 adult abdominal trauma patients (359 males, 176 females) who underwent CT examination after the ultrasonographic and physical examination were included in the study. Patients with penetrating abdominal injuries, intraabdominal ascites, patients whose files could not be accessed, those who were unconscious, those who did not undergo a physical examination, and those who were younger than 16 years were not included in the study. The age of the participants was between 16 years and 87 years (average: 37.5 years). Out of the total sample size, 162 (30.3%) patients had an extravehicular traffic accident, 23 (4.3%) had a motorcycle accident, 6 (1.1%) fell from a tractor, 304 (56.8%) had an intravehicular traffic accident, and 40 (7.5%) fell from a height (Table 1). ISS (injury severity score) and NISS (new injury severity score) scores of all patients were calculated. The mean ISS and NISS values of the patients were 8 (1–57) and 133 (24.9%). A total of 167 (31.2%) patients had an ISS and NISS score above 16 respectively.

Physical Examination The physical examination of patients who had applied to the emergency room with blunt abdominal trauma was carried out by our experienced physicians in the emergency department of Dışkapı Yıldırım Beyazıt Training and Research Hospital, which is also the main trauma center of our city. Unconscious and agitated patients who had refused to be examined due to severe pain were excluded from the study. As inspection, auscultation, and percussion would not be meaningful in the abdominal examination of these patients, the physical examination was limited to palpation. For the 370

Table 1. Demographic and clinical characteristics of the patients

n=535

Age (year), mean±SD Age interval (years)

37.5±18.0 16–87

Gender, n (%)

Male

359 (67.1)

Female

176 (32.9)

Etiology, n (%)

Intravehicular traffic accident

304 (56.8)

Extravehicular traffic accident

162 (30.3)

Motorcycle accident

Fall from tractor

6 (1.1)

Fall from height

40 (7.5)

23 (4.3)

Pelvis fractures, n (%)

89 (16.6)

56 (62.9)

Pubic ramus

Physical examination, n (%)

Tenderness 0

382 (71.4)

Tenderness 1

129 (24.1)

Tenderness 2

24 (4.5)

ISS

8 (1–57)

ISS >16, n (%)

NISS

133 (24.9) 8 (1–57)

NISS >16, n (%)

167 (31.2)

Clinical progress, n (%)

Nephrectomy

3 (0.6)

Splenectomy

26 (4.9)

Deaths

30 (5.6)

ISS: Injury severity score; NISS: New injury severity score; SD: Standard deviation.

convenience of the evaluation, palpation was categorized into three groups. - Tenderness 0: Absence of or minimal abdominal tenderness during the abdominal palpation. - Tenderness 1: Presence of prominent tenderness during the abdominal palpation. - Tenderness 2: Presence of defense or rebound during the abdominal palpation.

Imaging CT and US examinations were carried out in our radiology department by radiologists with at least 5 years of experience. US examination was performed in the supine position with the convex probe of the US device Esolute Mylab 60 and the abdomen of the patients was investigated. During the examination, all quadrants of the abdomen from the xiphoid to pelvis were thoroughly evaluated. As per standard US procedure, the presence of the intraabdominal free fluid was exUlus Travma Acil Cerrahi Derg, July 2019, Vol. 25, No. 4


Hekimoğlu et al. Comparison of US and physical examination with gold standard CT in patients with blunt abdominal trauma

amined first, after which the presence of intraabdominal solid organ lacerations was determined.

Table 2. Twelve patients with multiple organ trauma

After the US examination, the abdomen of the patients was scanned from diaphragm to pelvis with Toshiba Alexion 16 slice CT Scanner. Iohexol 300 mg I/mL was administered intravenously according to the weight of the patient with an Imaxeon syringe. All captured images were recorded in the hospital’s PACS System.

Liver Spleen Kidney Intestines

1 patient

+

+

+

3 patients

+

+

+

3 patients

+

+

4 patients 1 patient

+

+

+

+

+

Statistical Analysis Descriptive discrete numeric variables were shown with mean±standard deviation or median (minimum-maximum). Categorical variables were expressed as numbers of observations and percentage. The McNemar test was used to investigate whether the US and physical examinations had significant predictive value as compared to the gold standard CT with respect to identifying the cases. For every CT finding, sensitivity, specificity, positive estimated value, negative estimated value, and diagnostic accuracy rate related to the US and physical examination were calculated. The statistical compatibility of the findings of the US and physical examinations with the CT findings were evaluated by calculating the Kappa coefficient. A Kappa coefficient smaller than 0 was considered as the absence of compatibility; 0.0–0.20 indicated clinically insignificant compatibility; 0.21–0.40 indicated moderate compatibility; 0.41–0.60 indicated the compatibility for the majority; 0.61–0.80 indicated significant compatibility; and 0.81–1.00 indicated almost perfect compatibility.[16] The data analyses were done with IBM SPSS Statistics 17.0 (IBM Corporation, Armonk, NY, USA) package software. A p-value of <0.05 was considered statistically significant.

Table 3. Clinical findings with respect to the gold standard CT and alternative imaging method, US

CT - fluid None

Present

US - fluid

None

Present

340 (63.6%)

19 (3.5%)

27 (5.0%)

149 (27.9%)

CT - liver No laceration

Laceration

US - liver

No laceration

Laceration

490 (91.6%)

18 (3.4%)

2 (0.4%)

25 (4.6%)

CT - spleen No laceration

Laceration

US - spleen

No laceration

Laceration

471 (88.0%)

30 (5.6%)

3 (0.6%)

31 (5.8%)

CT - kidney

RESULTS

A total of 30 patients (5.6%) with high ISS and NISS scores died due to the extra-abdominal causes. In 367 of the participating 535 patients (68.6%), no pathological finding including the minimal fluid was determined. In 65 (38%) of the 168 patients with intraabdominal fluid (31.4%) minimal fluid was the only observed finding and these patients were discharged after a short hospitalization period. A total of 12 patients (2.2%) with organ injuries (7 patients with grade 1 liver injury, 1 patient with grade 1 spleen injury, 2 patients with minimal kidney injury, and 1 patient with intestinal injury) did not have intraabdominal free fluid except for the minimal fluid at the injury site. A total of 115 patients (21%) had organ injury and 12 of them (10.4%) had multiple organ injuries (Table 2).

US - kidney

While no fluid was observed in 340 patients (63.6%) during the US and physical examination, 149 patients (27.9%) Ulus Travma Acil Cerrahi Derg, July 2019, Vol. 25, No. 4

No laceration

Laceration

No laceration

Laceration

516 (96.4%)

14 (2.7%)

0 (0.0%)

5 (0.9%)

CT: Computerized tomography; US: Ultrasonography.

showed the presence of fluid in both US and CT examinations. The US findings were compatible with the CT findings regarding the identification of the patients with and without intraabdominal fluid (Kappa=0.808). In other words, the detection rate of the fluid was statistically comparable between the CT and US examinations (p=0.302) (Tables 3 and 4). Although the findings of US and CT were comparable regarding the detection of the hepatic, splenic and renal lacerations (Kappa: 0.695, 0.622, and 0.408 respectively), these lacera371


Hekimoğlu et al. Comparison of US and physical examination with gold standard CT in patients with blunt abdominal trauma

Table 4. Diagnostic performance indicators of the US as compared to the gold standard CT

Sensitivity (%)

Selectivity (%)

Positive estimated value (%)

Negative estimated value (%)

Ultrasonography

Fluid presence

88.7

92.6

84.7

94.7

Liver laceration

58.1

99.6

92.6

96.5

Spleen laceration

50.8

99.4

91.2

94.0

Kidney laceration

26.3

100.0

100.0

97.4

Table 5. Clinical findings of the patients with the organ injury with respect to the gold standard CT and alternative imaging method, US

CT - organ injury None

p† Kappa

Present

Total

Ultrasonography - organ injury, n (%)

None

Present

Total

417 (77.9)

58 (10.8)

3 (0.6)

57 (10.7)

420 (78.5)

115 (21.5)

<0.001

0591‡

475 (88.7) 60 (11.3) 535 (100.0)

Data; were expressed as the number of observations and percentage, †McNemar test, ‡Kappa coefficient was found as statistically significant (p<0.001).

Table 6. Frequency distributions of physical examination findings according to the gold standard CT

In CT no fluid

In CT only fluid was observed

In CT organ injury

Tenderness 0

Number of patients

309

50

23

According to physical examination (%)

80.9

13.1

6.0

According to CT (%)

87.0

76.9

20.0

Tenderness 1

Number of patients

46

15

68

According to physical examination (%)

35.7

11.6

52.7

According to CT (%)

13.0

23.1

59.1

Tenderness 2

Number of patients

0

0

24

According to physical examination (%)

0.0

0.0

100.0

According to CT (%)

0.0

0.0

20.9

CT: Computerized tomography.

tions were significantly clearer with CT as compared to US (p<0.001). In other words, it was found out that the rate of false negative results with US was significantly higher in the detection of the hepatic, splenic, and renal lacerations (Table 3, 4). With respect to the detection of at least one organ injury, findings of CT and US were comparable (Kappa=0.591), but the detection rate of organ injury with CT was significantly higher than US (p<0.001) (Table 5). CT is the gold standard for the detection of at least one organ injury. In compar372

ison to CT, the sensitivity, specificity, positive estimated value, negative estimated value, and accuracy rate of US were 49.6%, 99.3%, 95.0%, 87.8%, and 88.6% respectively. According to the results of the physical examination (palpation), 382 patients (71.4%) had tenderness 0, 129 (24.1%) had tenderness 1, and 24 (4.5%) had tenderness 2 (Table 6). In 309 of the 355 patients (87.0%) who presented with organ injury without fluid in CT, no tenderness was observed during the physical examination. On the other hand, 50 of Ulus Travma Acil Cerrahi Derg, July 2019, Vol. 25, No. 4


Hekimoğlu et al. Comparison of US and physical examination with gold standard CT in patients with blunt abdominal trauma

Table 7. Clinical findings of the patients according to the physical examination as compared to the gold standard CT

CT - liver No laceration

Laceration

Total

Physical examination, n (%)

Tenderness 0

375 (70.1)

7 (1.3)

382 (71.4)

Tenderness 1+2

117 (21.9)

36 (6.7)

153 (28.6)

Total

492 (92.0)

43 (8.0)

535 (100.0)

CT - spleen No laceration

Laceration

Tenderness 0

370 (69.2)

12 (2.2)

Tenderness 1+2

104 (19.4)

49 (9.2)

153 (28.6)

Total

474 (88.6)

61 (11.4)

535 (100.0)

CT - kidney No laceration

Laceration

p†

<0.001

382 (71.4)

<0.001

Total

Physical examination, n (%)

p†

p†

Total

Physical examination, n (%)

Tenderness 0

378 (70.6)

4 (0.8)

382 (71.4)

Tenderness 1+2

138 (25.8)

15 (2.8)

153 (28.6)

Total

516 (96.4)

19 (3.6)

535 (100.0)

<0.001

Data; were expressed as the number of observations and percentage, †McNemar test.

the 65 patients (76.9%) who had fluid without concomitant organ injury also had no tenderness during the physical examination. Only 23 of the 115 patients (20.0%) who had at least one organ injury in CT had no tenderness during the physical examination. Nevertheless, 68 of the 115 patients (59.1%) who had at least one organ injury in CT, had tenderness 1 during the physical examination and 24 (20.9%) had tenderness 2 (Table 6). Herewith, the sensitivity, specificity, positive estimated value, and negative estimated value were 59%, 87%, 70%, and 81% respectively as compared to the gold standard CT. The patients who either had no fluid in CT or solely had fluid in CT showed no defense or rebound during the physical examination. Only 24 (20.9%) of the 115 patients who had at least one organ injury in CT showed a defense or rebound during the physical examination. In other words, in all 24 patients who had a defense or rebound during the physical examination, at least one organ injury was detected with CT. To summarize, the rate of absence of tenderness during the physical examination decreased proportionally from the group without fluid in CT examination toward the group with at least one organ injury in CT examination. In comparison with the groups who had no fluid in CT or solely had fluid in CT, the group who had at least one organ injury in CT showed increased tenderness to physical examination, howUlus Travma Acil Cerrahi Derg, July 2019, Vol. 25, No. 4

ever, defense or rebound percentages showed a more significant increase. Separate statistical calculation of the physical examination findings for the organ injuries showed that the physical examination did not have a significant statistical predictive value in spite of its high sensitivity and specificity with respect to the identification of hepatic (83.7%, 76.2%), splenic (80.3%, 78.1%), and renal lacerations (78.9%, 73.3%) (p<0.001) (Table 7). On the other hand, 6 of the 9 patients with intestinal injury had tenderness 2 during the physical examination and 3 had tenderness 1. This showed that all patients with intestinal injury had a positive physical examination.

DISCUSSION It was clearly demonstrated that CT is a perfect imaging method for the evaluation of patients with blunt abdominal trauma. The early diagnosis enabled by CT contributes to the significant reduction of the morbidity and mortality related to traumatic abdominal injuries.[11] However, the common usage of the CT in recent years causes certain problems due to radiation exposure and its adverse effects, including the risk of future malignancies.[17] In our study, 367 (68.6%) of 535 patients who underwent CT examination had no pathological findings, including minimal fluid. Also, 65 (38%) of 168 373


HekimoÄ&#x;lu et al. Comparison of US and physical examination with gold standard CT in patients with blunt abdominal trauma

patients with intraabdominal fluid (31.4%) had minimal fluid and were discharged after a short hospitalization period. Only 115 patients of the participating 535 patients (21%) had a prominent pathological finding. We also took into consideration the patients who had only minimal fluid and were discharged without observation of any pathological finding, on the basis of which we suggested that CT examination was unnecessary in 79% of the patients. US examination was introduced into the investigation of the blunt abdominal trauma in the 1970s.[18] US examination usually is carried out with focused assessment with sonography in trauma (FAST) in trauma patients. This examination method enables a fast and general view into the intraperitoneal space to determine the presence of acute bleeding and free fluid, which is an indirect sign of visceral organ injury.[19â&#x20AC;&#x201C;21] According to the literature, US sensitivity was between 63% and 99% when evaluating the intraperitoneal fluid.[22,23] Meta-analyses showed that the sensitivity and specificity of the US examination were 80% and 96% respectively in pediatric trauma patients.[1] However, its sensitivity is significantly lower in the diagnosis of parenchymal injuries.[10] Furthermore, it has certain disadvantages such as a limitation in showing intestinal perforations and insufficient reliability in patients with intraabdominal ascites and obesity. In our study, the sensitivity, specificity, and accuracy of the US in comparison to the CT were 88.7%, 92.6%, and 91.5% respectively when showing the intraabdominal free fluid in patients with blunt abdominal trauma. The detection rate of the fluid was statistically comparable with CT (p=0.302). In their study, Kimura and Otsuka showed that US was a reliable method for the detection of the hemoperitoneum after blunt abdominal trauma.[24] They reported sensitivity, specificity, and accuracy rates (86.7%, 100%, and 97.2% respectively) that were very close to the results of our study. In their study, Katz and his colleagues reported that US was a sensitive and effective method to determine the presence of peritoneal free fluid and visceral organ injuries. The reported percentages of sensitivity, specificity, and accuracy were 90.9%, 83.6%, and 84.3% respectively.[25] However, the general statement in most of the studies in the literature was that the sensitivity of US was low in the detection of the organ injuries.[26,27] In our study, the evaluation of the organ injuries showed that the detection rate of the organ injuries with CT was significantly higher as compared to US (p<0.001). We found out that the sensitivity and specificity of US in detecting the organ injuries were 49.6% and 99.3% respectively. In blunt abdominal trauma, the spleen is the most commonly injured organ and constitutes 25%â&#x20AC;&#x201C;30% of the total intraabdominal injuries. The typical findings in the patients with large traumas were subcapsular hematoma and laceration of the splenic tissue.[28] As spleen injuries are a significant part of intraabdominal traumas, early diagnosis is critical to limit 374

morbidity and mortality.[29] The high blood perfusion of the spleen may cause fatal outcomes if its injuries are not timely taken into consideration.[30] In blunt abdominal traumas, the primary goal of the US examination of the spleen is to determine the presence of the blood in the left upper quadrant. [31] Except for the cases with no deterioration of the capsule integrity, hemoperitoneum in the left upper quadrant almost always indicates a splenic injury.[32] It was shown that US sensitivity was 72.4% in major splenic injuries and 57.8% in minor splenic injuries.[33] Richards and his colleagues found that the US sensitivity was 78% in Grade III and higher spleen injuries and stated that this level of sensitivity was insufficient for the spleen injuries with lower grades.[34] In our study, 61 patients (11.4%) had a splenic injury and 26 of them (42.6%) underwent splenectomy. Spleen laceration was detected in 34 (6.4%) patients with US and its sensitivity and specificity were calculated as 50.8% and 99.4% respectively. The detection rate of the spleen lacerations with CT was significantly higher than US (p<0.001). In other words, the rate of false negative results with US was significantly higher in the determination of spleen lacerations. In spite of the anatomical protection of the liver, it is the second most commonly injured organ in the blunt traumas. [35] It was reported that the rate of liver injuries in patients with blunt abdominal trauma was between 1% and 8%.[36] Most liver injuries occur in the posterior segment of the right lobe.[37] The major findings of the blunt abdominal trauma detected with CT are lacerations, subcapsular and parenchymal hematomas, active hemorrhage, and juxtahepatic venous injuries. Periportal low attenuation and flat inferior vena cava may be mentioned among minor CT findings. Bile leakage is common in hepatic lacerations, however, it is limited and transient in most of the cases and sequelae are not usually observed. Serious injuries that require treatment for intrahepatic or extrahepatic bile canals are relatively rare.[38] In their study, Marco et al.[33] found that in major liver injuries, sensitivity and specificity of US were 75% and 99.1% respectively and in minor liver injuries, they were 62.5% and 99.1% respectively. In our study, we detected liver laceration in 43 patients (8%) and only 4 of them (9.3%) underwent surgical intervention. US revealed laceration in 27 patients (5%) and the sensitivity and specificity were 58.1% and 99.6% respectively. The detection rate of liver lacerations with CT was significantly higher than US (p<0.001). In other words, the rate of false negative results was significantly higher in US regarding the detection of the liver lacerations. Although kidneys are the most commonly injured urogenital organs, their injury rate is lower than that of the spleen and liver. The risk of renal injury due to blunt trauma is higher in the pediatric population as compared to the adult population.[39] A pre-existing renal anomaly increases the risk of injury and kidney traumas are more common among children as compared to adults in the presence of kidney anomalies. Such injuries include the disruption of the renal pelvis or the Ulus Travma Acil Cerrahi Derg, July 2019, Vol. 25, No. 4


HekimoÄ&#x;lu et al. Comparison of US and physical examination with gold standard CT in patients with blunt abdominal trauma

ureteropelvic junction in patients with hydronephrosis, intracystic hemorrhage or renal cyst rupture, laceration of the ectopic or horseshoe kidney, and laceration of the infected kidneys.[40] Further, in their study, Marco et al.[33] reported the sensitivity and specificity in major kidney injuries as 30.7% and 97.6% respectively and in minor kidney injuries as 54.5% and 99.3% respectively. In our study, we detected kidney laceration in 19 patients (3.6%) and 3 of them (15.8%) underwent nephrectomy. Lacerations were detected in 5 patients (0.9%) with the US examination and consequently, the calculated sensitivity and specificity were 26.3% and 100% respectively. The detection rate of renal lacerations with CT was significantly higher than US (p<0.001). In other words, the rate of false negative results with US is significantly high regarding the kidney lacerations. Intestinal and mesenteric injuries were encountered in 5% of the blunt traumas. As the mortality rate due to these type of injuries is high, early diagnosis is critical.[41] The detection of intestinal injuries with US is extremely difficult. The characteristic findings include thickening of the intestinal wall, pneumoperitoneum, and presence of focal fluid.[42] Richard and his colleagues reported that 49% of the patients with intestinal and mesenteric injuries also present with injuries in other organs. It was reported that the sensitivity of US for the detection of the free fluid was 44% in isolated intestinal and mesenteric injuries.[43] In their study, Abu-Zidan et al.[44] were not able to detect any of the 3 intestinal injuries with US and thus they reported the sensitivity of US as 0%. In our study, we observed intestinal perforation in 9 patients (1.7%) and it was concomitant with spleen, liver, and right kidney lacerations in 1 patient and with the liver laceration in another patient. We detected isolated intestinal injury in only 7 patients. US examination revealed prominent fluid in all patients except 1, in whom we could not even detect fluid with US and loculated fluid was observed around the colon in the CT examination. As only fluid was observed and no other prominent pathological finding was detected in the intestinal and mesenteric injuries with US, we also considered the sensitivity of US as 0%.

had a sensitivity of 39% and a specificity of 90% in the determination of the intraabdominal hemorrhage. Another study demonstrated that physical examination caused false results in one-third of the patients with blunt abdominal trauma.[46] In such studies, the investigators especially emphasized that patients who had clouding of consciousness due to cranial trauma or extra-abdominal trauma did not show an optimal response to the physical examination. However, in another study conducted by Ferrera and colleagues, the sensitivity and specificity of the physical examination were 82% and 45% respectively in blunt abdominal traumas.[47] In our study, an overall calculation of the sensitivity, specificity, positive estimated value, and negative estimated value of the physical examination for all patients displayed rates of 59%, 87%, 70%, and 81% respectively. Furthermore, Ferrera and colleagues reported that they detected intraabdominal injuries in 7% of the patients with normal physical examination.[47] In our study, 87% of the patients with no pathological finding on CT also had a normal physical examination. However, 59.1% of the patients had tenderness 1 and 20.9% had tenderness 2, so the rate of positive findings in the physical examination was 80%. Separate statistical calculations for patients with liver, spleen, and kidney lacerations were performed and the sensitivity and specificity of the physical examination were 83.7% and 76.2% respectively for the liver, 80.3% and 78.1% respectively for the spleen, and 78.9% and 73.3% for the kidney, which was statistically not comparable with CT (p<0.001). On the other hand, all 9 patients with intestinal injury also had positive symptoms during the physical examination. The most important finding of our study was that the patients with tenderness score 2 (the presence of defense and rebound during the palpation) had at least one organ injury. Eventually, the rate of the tenderness during the physical examination increased proportionally from the group without any pathological finding in CT examination toward the group with at least one organ injury in CT examination. Nevertheless, we were not able to achieve the exact desired results in the other two groups except the group with defense and rebound.

In our study, US did not directly show any of the intestinal or mesenteric injuries and in our opinion, it might be also incapable of detecting injuries of the diaphragm, pancreas, adrenal gland, and bone. Its usefulness is probably also limited in several vascular injuries.[27] As a result, US is not a reliable method in the determination of injuries except in assessing the free fluid in the blunt abdominal traumas. Moreover, we noticed that the reliability of the US examination is more decreased if 12 patients (2.2%) who had minimal organ injury without prominent free fluid were taken into consideration.

Conclusion

A physical examination is traditionally an important tool in assessing the general condition of the patient. Soyuncu et al.[45] compared the reliability of the physical examination with the US examination and reported that the physical examination

We found an abundant number of unnecessary CT examinations, especially with respect to discharged patients with minimal fluid and no other pathologies during follow up. Although the reliability of US in the determination of the intraabdominal fluid is well established, its reliability in the

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Finally, we observed pelvic fractures in 89 patients (16.6%). In 56 of them, the fracture was located in the pubic ramus. The most common extra-abdominal injury is the pelvic fracture in trauma patients, especially fractures of the pubic ramus. The mortality rate in patients with untreated pelvic fractures is between 4% and 15%.[48]

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Hekimoğlu et al. Comparison of US and physical examination with gold standard CT in patients with blunt abdominal trauma

detection of organ injuries is rather limited. The findings also indicated that physical examination is not a reliable tool for diagnosis in traumatic patients. Therefore, CT is currently the best method for the early diagnosis of patients with traumatic organ injury if used with the correct indication. Conflict of interest: None declared.

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45. Soyuncu S, Cete Y, Bozan H, Kartal M, Akyol AJ. Accuracy of physical and ultrasonographic examinations by emergency physicians for the early diagnosis of intraabdominal haemorrhage in blunt abdominal trauma. Injury 2007;38:564−9. 46. Perry Jf Jr. A Five-Year Survey of 152 Acute Abdominal Injuries. J Trauma 1965;5:53−61.

43. Richards JR, McGahan JP, Simpson JL, Tabar P. Bowel and mesenteric injury: evaluation with emergency abdominal US. Radiology 1999;211:399−403.

47. Ferrera PC, Verdile VP, Bartfield JM, Snyder HS, Salluzzo RF. Injuries distracting from intraabdominal injuries after blunt trauma. Am J Emerg Med 1998;16:145−9.

44. Abu-Zidan FM, Sheikh M, Jadallah F, Windsor JA. Blunt abdominal trauma: comparison of ultrasonography and computed tomography in a district general hospital. Australas Radiol 1999;43:440−3.

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ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Künt karın travmalı hastalarda ultrasonografi ve fizik muayenenin bilgisayarlı tomografi ile karşılaştırılması Dr. Azad Hekimoğlu,1 Dr. Onur Ergun,1 Dr. Seda Özkan,2 Dr. Engin Deniz Arslan,2 Dr. Baki Hekimoğlu1 1 2

Dışkapı Yıldırım Beyazıt Eğitim ve Araştırma Hastanesi, Radyoloji Kliniği, Ankara Dışkapı Yıldırım Beyazıt Eğitim ve Araştırma Hastanesi, Acil Tıp Kliniği, Ankara

AMAÇ: Künt travmalarda karın bölgesi üçüncü en sık etkilenen yerdir. Bu hastaların değerlendirilmesinde bilgisayarlı tomografi (BT) altın standarttır. BT’nin hastaya olan zararlı etkileri ve maliyet yönünden düşünüldüğü zaman her acil servise gelen hastaya çekilmesi uygun bir yaklaşım olmayabilir. Çalışmamızda künt batın travması ile acil servise gelen hastaların ultrasonografi (US) ve fizik muayene bulgularının altın standart olan BT ile karşılaştırılması yapılarak gereksiz BT çekimlerinin önüne geçilmesi amaçlandı. GEREÇ VE YÖNTEM: Hastanemiz acil servisine batın travması ile gelen 2248 hastanın dosya ve görüntüleri geriye dönük olarak tarandı ve çalışmaya uygun olan ve acil servisteki fizik muayenesinin ardından US ve sonrasında BT çekilen 535 yetişkin hasta çalışmaya alındı. Karın içi serbest sıvı ve organ laserasyonlarının US ve fizik muayene bulguları BT sonuçları ile ayrı ayrı karşılaşırıldı. Elde edilen değerlerin uyumluluk, duyarlılık, özgüllük, pozitif ve negatif tahmini değerleri istatistiksel olarak hesaplandı. BULGULAR: Künt batın travmalı hastalarda US’nin karın içi serbest sıvıyı gösterme duyarlılığı BT ile istatistiksel olarak benzerdi (p=0.302). Karın içi organ yaralanmalarının saptanmasında ise US’nin duyarlılığı %49.6, özgüllüğü %99.3 olarak bulundu. Fizik muayenenin ise BT’ye göre serbest sıvı ve organ yaralanmasının saptanmasında genel duyarlılığı %59, özgüllüğü %87 olarak hesaplandı. Organ yaralanmaları için ayrı ayrı istatistiksel olarak hesaplandığı zaman fizik muayenenin duyarlılık ve özgüllüğünün yüksek olmasına rağmen istatistiksel olarak anlamlı bir belirleyiciliğinin olmadığı görüldü (p<0.001). TARTIŞMA: Ultrasonografinin karın içi sıvı saptanmasında gerçekten güvenilir bir yöntem olduğu anlaşılmakla birlikte organ yaralanmalarının saptanmasında US ve fizik muayenenin güvenilir olmadığı görülmektedir. Anahtar sözcükler: Batın; fizik muayene; tomografi; travma; ultrasonografi. Ulus Travma Acil Cerrahi Derg 2019;25(4):369-377

doi: 10.5505/tjtes.2018.88288

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ORIG I N A L A R T IC L E

How necessary is the computerized brain tomography in minor head trauma? Serhat Yıldızhan, M.D.,1

Mehmet Gazi Boyacı, M.D.,1

Şerife Özdinç, M.D.2

1

Department of Neurosurgery, Afyonkarahisar Health Sciences University Faculty of Medicine, Afyonkarahisar-Turkey

2

Department of Emergency Medicine, Afyonkarahisar Health Sciences University Faculty of Medicine, Afyonkarahisar-Turkey

ABSTRACT BACKGROUND: Head trauma is a health problem that may be observed in all age groups, and it may cause significant losses in terms of health and economy. The purpose of our study is to evaluate the abnormal computerized brain tomography (CBT) prevalence and the rate of admission to brain surgery clinics in patients who applied to the Emergency Service Department for CBT due to minor head trauma. METHODS: In the present study, the patients who were admitted to Afyonkarahisar Health Sciences University, Faculty of Medicine Hospital, Emergency Service Department between January 1st, 2017, and December 31st, 2017, due to head trauma and in who CBT was performed were examined retrospectively. The electronic files, CBTs, and consultation notes of these patients were accessed in the information system of the hospital. RESULTS: A total of 43,389 patients who applied to the Emergency Service Department in 1 years’ time (2017) were examined retrospectively. As a result of the examination, it was determined that a total of 2,515 (5.7%) patients received CBT. The reason for a total of 1,152 (45%) of these patients was traumatic injury. It was determined that 618 (53.6%) of the patients in who CBT was performed due to trauma were aged <18 years; 280 (24.3%) patients were aged <2 years; 179 (15.5%) patients had to consult with the Brain Surgery Clinic; and 94 (8.1%) were hospitalized. It was also determined that there were abnormal computed tomography (CT) findings in only 68 (5.9%) of the patients in who CBT was performed. CONCLUSION: The use of CBT indication criteria, which have been previously established and which reliability has been proven, in emergency trauma cases applying to the Emergency Service Department with minor head traumas may reduce the complication risk that may appear as a result of an unnecessary CBT and avoid complications that may occur in the long run due to CBT. Keywords: Computerized computed tomography; minor head trauma; rules for computed tomography.

INTRODUCTION The number of applications to the Emergency Service Department is increasing every day. Approximately half of these applications consist of trauma patients. Traumatic brain injuries (TBI) are observed frequently and progress with a bad prognosis when they are severe. TBIs are the primary cause of death in people aged <45 years and are most commonly mildly severe in the population. In addition, approximately 8%–10% of these are moderate or severe.[1] Computerized brain tomography (CBT) as a result of the developments in technology is used increasingly in patients who present with

head trauma to the Emergency Service Department. The radiation received during CBT poses a greater risk, especially in the pediatric patient groups. The aim of our study is to evaluate the prevalence of abnormal CBT and the rate of admission to brain surgery clinics of patients in who CBT was performed and who applied to the Emergency Service Department due to head trauma.

MATERIALS AND METHODS In the present study, the patients who applied to Afyonkarahisar Health Sciences University, Faculty of Medicine

Cite this article as: Yıldızhan S, Boyacı MG, Özdinç Ş. How necessary is the computerized brain tomography in minor head trauma?. Ulus Travma Acil Cerrahi Derg 2019;25:378-382. Address for correspondence: Serhat Yıldızhan, M.D. Afyonkarahisar Sağlık Bilimleri Üniversitesi Tıp Fakültesi, Beyin ve Sinir Cerrahisi Anabilim Dalı, Afyonkarahisar, Turkey Tel: +90 272 - 246 33 01 E-mail: serhatyildizhan07@gmail.com Ulus Travma Acil Cerrahi Derg 2019;25(4):378-382 DOI: 10.5505/tjtes.2018.94849 Submitted: 13.07.2018 Accepted: 23.11.2018 Online: 08.07.2019 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

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Yıldızhan et al. How necessary is the computerized brain tomography in minor head trauma?

Hospital, the Emergency Service Department between January 1st, 2017, and December 31st, 2017, due to head trauma and in who CBT was applied, were examined retrospectively. From the hospital information system and the electronic files of these patients, age, gender, trauma causes, examination findings, consciousness levels, and the Glasgow Coma Scale values, reasons for CBT, consultation notes, and result information were accessed. Patients were classified according to their consciousness levels, CBT indications, and clinical diagnosis after CBT. The patients who requested counseling and who were hospitalized were also evaluated. Data obtained in this way were analyzed using the Descriptive Statistical Analyses SPSS 22.0 Software (IBM, New York, USA). The present study was approved by Afyonkarahisar Health Sciences University, Clinical Research Ethics Board.

RESULTS It was determined that a total of 43,389 patients applied to the Emergency Service Department within 1 year (2017). As a result of the examination, it was determined that 2,515 (5.7%) patients received CBT. The reason for application in a total of 1,152 (45%) of these patients was traumatic injury. Among the trauma causes, traffic accidents (40.6%) were listed first as the most frequent, and simple falls (36.4%) were listed second. It was also determined that a total of 618 (53.6%) patients who received CBT were under aged <18 years, and 648 (56.2%) patients were male. It was found that 179 (15.5%) patients who received CBT consulted with the Brain Surgery Clinic; 94 (8.1%) were admitted to the Brain

Surgery Clinic; and 128 (11.1%) patients were admitted to other clinics. Patients were divided into groups according to consciousness levels (Table 1). It was also determined that a great many of the patients (85.7%) had a mild mental state of consciousness. When patients with trauma-related CBT and their files were evaluated in an accurate manner, it was determined that having only a head trauma (n=246; 38.6%) was the most common complaint, and nausea and vomiting (n=146; 22.9%) were the second most common complaints (Table 2). It was observed that only 68 of the patients (5.9%) had abnormal CBT findings. The most common clinical condition was linear fractures (Table 3).

DISCUSSION Today, applications to the Emergency Service Department are increasing every day. In 2017, the number of emergency service applications in our country exceeded 100 million. Important increases are observed in imaging methods due to reasons such as a high number of Emergency Service Department applications, an increase in the quality of imaging methods due to technological developments, defensive practices of consultation with doctors, an inadequate number of health care staff, social reasons, physical insufficiency of the emerTable 3. Clinical features of patients hospitalized in the brain surgery department Diagnosis

Patient number

Subarachnoid bleeding

18

Linear fractures

26

Table 1. The post-traumatic consciousness levels in the patients who underwent CBT

Collapsing fractures

12

Epidural, subdural hematoma

20

Consciousness level

Intraparenchymal hematoma

8

No CBT pathologies were detected

14

Glasgow Coma Scale

Patient count

Light

14–15

988 (85.7%)

Mild

8–13

116 (10.0%)

Severe

3–8

48 (4.3%)

Table 4. The criteria showing that the intracranial damage risk is low

CBT: Computerized brain tomography.

Table 2. Complaints of the patients undergoing CBT in the emergency service department at admission Complaint at admission

CBT: Computerized brain tomography.

Patient number

Head trauma (no symptoms)

246

The absence of the following symptoms must be determined clinically Changes in the consciousness Behavioral disorders Increase in the headache

Nausea-vomiting 146

Speech disorders

Multi-trauma 105

Weakness or loss of sense in arms or legs

Loss of consciousness

Continuous vomiting

63

Amnesia 50

Expansion in one or both of the pupils and no reaction to light

Epileptic seizures

Epilepticseizures

CBT: Computerized brain tomography.

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26

Significant increase in the swelling in the damage area

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GCS=14 Mental status change or palpable skull fracture

YES

Perform CBT

NO YES

Tomography may be needed in the light of the following evaluations: - The experience of the doctor - Deterioration in symptoms in the follow-up in the emergency service department - Guidance of the parents - Agebeing <3 months

- Hematoma in the occipital, parietal, temporal scalp - ≥5-second loss of consciousness in anamnesis - Severe trauma mechanism - Abnormal parental behavior

NO CBT not recommended

PECARN tomography criteria for patients aged >2 years GCS=14 Changes in mental status or skull base fracture symptoms

YES

Perform CBT

NO YES Tomography may be needed in the light of the following evaluations: - The experience of the doctor - Deterioration in symptoms during follow-up in the emergency service department - Guidance of the parents

Loss of consciousness in the anamnesis Vomiting Severe trauma mechanism Severe headache

NO CBT not necessary

Figure 1. PECARN tomography criteria for patients aged <2 years.

gency departments, and an increase in abuse cases. The method that applies the highest radiation levels to the body is CBT when compared to other imaging methods. An effective dose is 2-4 mSv when performing CBT. This dose contains approximately 200 times more radiation than a lung graphics. Cell proliferation is faster in children, and radiation poses a greater risk when compared to adults because it affects the cells that reproduce at a great speed. Although these facts are known, the rate of using computed tomography (CT) is still increasing.[2] One of the most common causes of applications to the Emergency Service Department is head trauma, and it is the most important cause of mortality and morbidity, especially in childhood. Falls, traffic accidents, and sports injuries are the most common causes of head traumas. Melo et al.[3] conducted a study and reported that the most frequent cause of head trauma was falling from high places with 72%. Güzel et al.[4] conducted a study and reported that falls were the most frequent reason with a rate of 49.5%. Işık et al.[5] conducted another study and reported that the causes of head traumas were simple falls with 70% and traffic accidents 380

with 18%. Gürses et al.,[6] on the other hand, reported that the reasons of head traumas were traffic accidents (46%), falls (39%), and bicycle accidents (15%). In our study, traffic accidents were the first (40.6%), and simple falls were the second (36.4%). The rate of performing CBT is higher in pediatric patients than in adult patients. Among the reasons, it is possible to name the fast deterioration of the clinical symptoms in children with TBI, difficult observation, social indications, abuse cases, and doctors’ desire to avoid taking risks. Recently, many studies have been conducted to determine the effective use of CBT in patients with mild head traumas to reduce the number of CBT as much as possible.[7,8] Osmond et al.[9] conducted a study with 3,866 children that had a mild head trauma and reported that 52.8% of these children had CBT, only 4.1% had brain damage, and 0.6% underwent surgery. In a study conducted by Atabaki et al.,[10] it was reported that after the CBT was performed in 1,000 children with mild head trauma, intracranial injury was detected only in 6.5% of the patients, and only 0.6% of these patients underwent surgery. In addition, clinical rules must be defined for CBT, Ulus Travma Acil Cerrahi Derg, July 2019, Vol. 25, No. 4


Yıldızhan et al. How necessary is the computerized brain tomography in minor head trauma?

and these rules must be employed in performing CBT. In a study conducted by Er et al.,[11] a total of 314 pediatric patients were examined, and it was determined from CBT results that no surgical interventions were necessary for 19 patients (6%), although pathological CBT results were determined. In our study, 1,152 (42.9%) of the 2,682 patients who applied to the Emergency Service Department due to head trauma were found to have undergone CBT, and 618 (53.6%) of these were aged <18 years. A total of 280 of these patients (24.3%) were 0–2 years. A total of 94 patients (8.1%) were hospitalized, and 68 (5.9%) had abnormal CT findings. The most frequent clinical finding were linear skull fractures. It was also determined that 24 patients (2.0%) underwent surgery. In a study conducted by Lyttle et al., the three current algorithms were compared: PECARN, CATCH, and CHALICE (Children’s Head Injury Algorithm for Prediction of Important Clinical Events), which were used in clinical decision-making processes for children with mild head trauma to avoid unnecessary radiation. As a result of the study, the PECARN algorithm (Fig. 1) was found to be more sensitive than the CATCH and CHALICE algorithms, and PECARN rules recommended that CBT should be performed.[12] In this study, when the patients were re-evaluated by taking the PECARN criteria as the basis according to physical examination findings and clinical complaints, it was determined that 98 patients (35%) out of 280 patients under aged <2 years were found to be followed up without CBT. When the results of the 338 patients aged 2–18 years were re-evaluated in respect to the PECARN criteria, it was found that 68 (20%) patients would be treated without CBT. According to these results, it is understood that as the age decreases, the CBT performing reflex also increases. In a multidisciplinary study that involved 7,035 patients with head traumas,[13] the patients were grouped as low, moderate, and high-risk based on the intracranial injury levels (Table 4). According to this classification, CBT was not recommended for the patients with low risk for intracranial injury; however, patients with moderate to high risk were recommended to undergo CBT. In our study, when the 340 patients whose files could be examined in detail out of the 504 patients who underwent CBT were evaluated, it was determined that 66 (19.4%) patients had undergone CBT although they were in the low-risk group for intracranial injury. When 636 patients who had undergone CBT and whose files could be examined accurately were examined, it was determined that in 246 (38.6%) of patients, the most frequent reason for presenting to the Emergency Service Department was the head trauma without any symptoms in the patients. There were no clinical complaints in these patients. The second most common reason for application to the Emergency Service Department was nausea and vomiting with 146 (22.9%) patients. Only 68 patients (5.9%) patients who underwent CBT had abnormal CBT findings. The most frequently observed clinical condition were linear fractures. Ulus Travma Acil Cerrahi Derg, July 2019, Vol. 25, No. 4

Conclusion CBT is an important imaging method used in children, and it has been employed more frequently in pediatric patients in recent years parallel to the developments in the IT technology. Today, complete adherence to the algorithms related to the use of CBT leads us away from unnecessary CBT and its longterm unwanted effects. With this study, it was determined that the number of CBTs may be reduced by applying the CBT indications whose reliability was proven in the presence of minor head traumas in patients admitted to the Emergency Service Department of our hospital due to head trauma. Conflict of interest: None declared.

REFERENCES 1. Thornhill S, Teasdale GM, Murray GD, McEwen J, Roy CW, Penny KI. Disability in young people and adults one year after head injury: prospective cohort study. Br Med J 2000:320:1631−5. 2. Macias CG, Sahouria JJ. The appropriate use of CT: quality improvement and clinical decision-making in pediatric emergency medicine. Pediatr Radiol 2011;41 Suppl 2:498–504. 3. Melo JR, Di Rocco F, Lemos-Júnior LP, Roujeau T, Thélot B, Sainte-Rose C, et al. Defenestration in children younger than 6 years old: mortality predictors in severe head trauma. Childs Nerv Syst 2009;25:1077−83. 4. Güzel A, Ceylan A, Tatli M, Başoğul M, Ozer N, Kahraman R, et al. Falls from height in childhood in Diyarbakir province: A questionnaire study combined with clinical data. Ulus Travma Acil Cerrahi Derg 2009;15:277−84. 5. Işık HS, Gökyar A, Yıldız Ö, Bostancı U, Özdemir C. Çocukluk çağı kafa travmaları, 851 olgunun retrospektif değerlendirilmesi: Epidemiyolojik bir çalışma. Ulus Travma Acil Cerrahi Derg 2011;17:166−72. 6. Gürses D, Sarıoğlu Büke A, Başkan M, Herek Ö, Kılıç İ. Travma nedeniyle çocuk acil servise başvuran hastaların epidemiyolojik değerlendirilmesi. Ulusal Travma Derg 2002;8:156−9. 7. Maguire JL, Boutis K, Uleryk EM, Laupacis A, Parkin PC. Should a head-injured child receive a head CT scan? A systematic review of clinical prediction rules. Pediatrics 2009;124:145−54. 8. Dunning J, Daly JP, Lomas JP, Lecky F, Batchelor J, Mackway-Jones K; Children’s head injury algorithm for the prediction of important clinical events study group. Derivation of the children’s head injury algorithm for the prediction of important clinical events decision rule for head injury in children. Arch Dis Child 2006;91:885−91. 9. Osmond MH, Klassen TP, Wells GA, Correll R, Jarvis A, Joubert G, et al. CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury. CMAJ 2010;182:341−8. 10. Atabaki SM, Stiell IG, Bazarian JJ, Sadow KE, Vu TT, Camarca MA, et al. A clinical decision rule for cranial computed tomography in minor pediatric head trauma. Arch Pediatr Adolesc Med 2008;162:439−45. 11. Er A, Akman C, Alatas İ, Ünlü HB, Ceylan I, Gün C, ve ark. Minör Kafa Travması Olan Çocuklarda Rutin Olarak BT Yapmalı mıyız? JOPP Derg 2013;5:131−5. 12. Lyttle MD, Crowe L, Oakley E, Dunning J, Babl FE. Comparing CATCH, CHALICE and PECARN clinical decision rules for paediatric head injuries. Emerg Med J 2012;29:785−94. 13. Masters SJ, McClean PM, Arcarese JS, Brown RF, Campbell JA, Freed HA, et al. Skull x-ray examinations after head trauma. Recommendations by a multidisciplinary panel and validation study. N Engl J Med 1987;316:84−91.

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ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Minör kafa travmasında bilgisayarlı beyin tomografisi ne kadar gerekli? Dr. Serhat Yıldızhan,1 Dr. Mehmet Gazi Boyacı,1 Dr. Şerife Özdinç2 1 2

Afyonkarahisar Sağlık Bilimleri Üniversitesi Tıp Fakültesi, Beyin ve Sinir Cerrahisi Anabilim Dalı, Afyonkarahisar Afyonkarahisar Sağlık Bilimleri Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Afyonkarahisar

AMAÇ: Kafa travmaları tüm yaş gruplarında görülebilen, sağlık ve ekonomi açısından önemli kayıplara neden olabilen bir sağlık sorunudur. Çalışmamızın amacı, acil servise minör kafa travması nedeniyle başvuran ve bilgisayarlı beyin tomografisi (BBT) çekilen hastalarda, anormal BBT prevalansını ve beyin cerrahi kliniğine yatış oranlarını değerlendirmektir. GEREÇ VE YÖNTEM: Çalışmada Afyonkarahisar Sağlık Bilimleri Üniversitesi Tıp Fakültesi Hastanesi Acil Servisi’ne 01.01.2017–31.12.2017 tarihleri arasında kafa travması nedeniyle gelen ve BBT çekilen hastalar geriye dönük olarak incelendi. Hastane bilgi sisteminden bu hastaların elektronik dosyalarına, BBT’lerine ve konsültasyon notlarına ulaşıldı. BULGULAR: Bir yıllık (2017) süre içerisinde acil servise başvuru yapan 43.389 hastaya ulaşıldı. İnceleme sonucunda 2515 (%5.7) hastaya BBT çekildiği saptandı. Bu hastaların 1152’sinin (%45) başvuru nedeni travma idi. Travmaya bağlı olarak BBT çekilen 618 (%53.6) hastanın 18 yaş altı olduğu, 280 (%24.3) hastanın iki yaş altı olduğu, 179 (%15.5) hastanın beyin cerrahisi kliniği ile konsülte edildiği ve 94 (%8.1) hastaya yatış verildiği saptandı. BBT çekilen sadece 68 (%5.9) hastada anormal BT bulguları saptandı. TARTIŞMA: Acil servise minör kafa travması ile gelenlerde, daha önce tespit edilen ve güvenilirliği kanıtlanan BBT çekim endikasyon kriterlerinin kullanılması, düşük riskli hastaların takip edilmesi, gereksiz BBT çekimlerini ve çekime bağlı uzun dönemde gelişebilecek komplikasyonları azaltabilir. Anahtar sözcükler: Beyin tomografisi çekim kuralları; bilgisayarlı beyin tomografisi; minör kafa travması. Ulus Travma Acil Cerrahi Derg 2019;25(4):378-382

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doi: 10.5505/tjtes.2018.94849

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ORIG I N A L A R T IC L E

Retrospective analysis of decompressive craniectomy performed in pediatric patients with subdural hematoma M. Özgür Taşkapılıoğlu, M.D.,1

Ali İmran Özmarasalı, M.D.,1

1

Department of Neurosurgery, Uludağ University Faculty of Medicine, Bursa-Turkey

2

Department of Biostatistics, Uludağ University Faculty of Medicine, Bursa-Turkey

Gökhan Ocakoğlu, M.D.2

ABSTRACT BACKGROUND: The impact of decompressive craniectomy (DC) on the overall outcome of pediatric acute subdural hematoma patients has not been fully determined to date. In this paper, we aimed to investigate the role of decompressive craniectomy performed to treat traumatic subdural hematoma in patients from the pediatric age group. METHODS: We described our experience with DC in pediatric acute subdural hematoma patients and analyzed the outcomes. RESULTS: Eleven (7 unilateral and 4 bilateral) DCs were performed. The patients’ ages ranged from 8 months to 15 years. The mean GCS score at admission was 7.8. All patients underwent DC with duraplasty within 2 hours of injury. All the patients were admitted to the intensive care unit for 10 days postoperatively. The mean hospital stay was 22 days and the mean follow-up period was 3.7 years. CONCLUSION: Early DC for pediatric subdural hematoma patients, independent of their initial GCS, was recommended. Larger studies are needed to define the indications, surgical techniques, and timing of DC in the pediatric population. Keywords: Acute subdural hematoma; decompressive craniectomy; head injury.

INTRODUCTION Head injury is the leading cause of disability and death in children and adolescents.[1] In the United States, more than one million head injuries happen in the pediatric age group. [2] Motor vehicle crashes, falls, sports, and abuse/assault are the most frequent causes of head injury.[2] Despite advances in brain monitoring and medical management of intracranial hypertension, the morbidity and mortality rates are still high.[3] Acute subdural hematoma (SDH) results in approximately one-third of the total traumatic head injuries.[4] Its mortality rate ranges from 40–60% and functional recovery rate ranges from 19–45%.[5] Recent trauma guidelines for surgical management of SDH stated that surgical evacuation of an acute SDH is indicated

if its thickness exceeds 10 mm or the midline shift exceeds 5 mm regardless of the Glasgow Coma Scale (GCS) score. In patients with a GCS score of less than 9, evacuation may be indicated independent from the volume of SDH.[6] Decompressive craniectomy includes elevating a bone flap, evacuating the hematoma, and storing the bone flap to accommodate the expansion of edematous cerebral tissue. This facilitates the management of intracranial pressure (ICP), which is the preferred management strategy for SDH.[7] Many studies have previously researched the role of decompression craniectomy (DC) for SDH but few studies were done for the pediatric age group. In this manuscript, we aimed to investigate the role of decompressive craniectomy at traumatic subdural hematoma in the pediatric age group.

Cite this article as: Taşkapılıoğlu MÖ, Özmarasalı Aİ, Ocakoğlu G. Retrospective analysis of decompressive craniectomy performed in pediatric patients with subdural hematoma. Ulus Travma Acil Cerrahi Derg 2019;25:383-388. Address for correspondence: M. Özgür Taşkapılıoğlu, M.D. Uludağ Üniversitesi Tıp Fakültesi, Beyin ve Sinir Cerrahisi Anabilim Dalı, Bursa, Turkey Tel: +90 224 - 295 27 40 E-mail: ozgurt@uludag.edu.tr Ulus Travma Acil Cerrahi Derg 2019;25(4):383-388 DOI: 10.5505/tjtes.2018.02403 Submitted: 27.07.2018 Accepted: 22.11.2018 Online: 08.07.2019 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

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MATERIALS AND METHODS This study was performed with the permission of the Ethical Committee of Uludag University School of Medicine, Bursa, Turkey (2018-13/9). We retrospectively reviewed the clinical records of 11 children with SDH who were treated with DC in a tertiary university hospital during a period of 18 years (2000–2018). Descriptive statistics included age and sex, mechanism of injury, Glasgow Coma Scale (GCS) score on arrival at the hospital, minimum GCS score, neurological examination on admission, and computed tomography (CT) findings. The variables related to DC included indications for the procedure, timing of the surgery, surgical technique, and the area of decompression. Outcome variables consisted of modified Rankin score (mRS) and the immediate and long-term complications associated with the intervention.

Surgical Procedure Out of 11 patients, 7 patients (63%) underwent unilateral frontotemporoparietal craniectomy. Bifrontal craniectomy was performed in 4 cases (36%). The dura mater was opened and duraplasty was performed with galea or artificial prostheses in all cases. ICP was not monitored because of the urgency of the condition. The bone fragment was stored cold at -19.5 °C in a deep freeze dedicated as the bone bank. The bone fragments were replaced in the first month in 1 patient, in the second or third month in 3 patients, and after the sixth month in 4 patients.

Case Presentation A 20 month-old female infant was admitted to the emergency department following a head injury due to a fall from the second floor (patient #6). She was intubated, unconscious, and had no response to light in both pupils. Her GCS was 3. A right frontotemporoparietal subdural hematoma was detected and she was operated with a right frontotemporoparietal craniectomy. The hematoma was evacuated and an intracranial pressure monitoring kit was placed (Codman® MicroSensor, Codman & Shurtleff Inc, Raynham, MA, USA).

(a)

(b)

The opening pressure was 3 mmHg. The cold stored bone flap was replaced 1.5 months after the operation. At the 4-year follow-up, she was neurologically intact and her only complaint was of a headache (Fig. 1).

RESULTS We performed a total of 11 DCs. None of the patients died and the outcome was favorable in the survivors (Table 1). The patients’ ages ranged from 8 months to 15 years (median age: 48 months). Out of 11 patients, 5 patients (45.5%) were boys and 6 (54.5%) were girls. The causes of injury were as follows: fall from a height (4 patients), traffic accident (5 patients), and hit by an object (1 patient). On admission, 6 patients had a GCS score of ≤8 (54.5%) and 5 patients had a GCS score of >9. The mean GCS score in our sample was 7.8. One patient (9.09%) presented with initial anisocoria. All patients underwent DC with duraplasty within 2 hours of injury. All the patients were followed-up at the intensive care unit for 10 days postoperatively. The fastest time taken to perform DC was 1 hour and the longest was 7 hours (median DC time: 4 hours). The median decompression area was calculated as 325 cm2 (157.50:792). The median cranioplasty time was 4.50 months (1:12) after the operation and the mean hospital stay was 22 days. The mean follow-up period was 3.7 years. The mRS ranged from 1–4 (median mRS score: 3) at discharge and the median mRS was 1.6 at follow-up.

Complications The most frequent complications were seizure and infection. Two patients developed meningitis and wound infection was detected in 2 patients. Seven patients (63%) experienced aseptic resorption of the bone flap. Three patients required an additional cranioplasty (Table 1).

Statistics Due to the young patient age, the preoperative GCS, decompression time, decompression area, mRS score, and cranioplasty time did not follow normal distribution according to

(c)

(d)

Figure 1. (a, b) Preoperative CT showing right frontotemporoparietal subdural hematoma; (c, d) Postoperative CT with parenchyma and bone window presenting decompression.

384

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3

6

1

Decompression time

0.19

0.571

Cranioplasty time

0.21

0.556

Preoperative Glasgow Coma Scale

-0.18

0.599

Decompression area

-0.21

0.531

Age

-0.24 0.484

mRS: Modified Rankin score; rs: Spearman correlation coefficient.

mRSd: Modified Rankin score at discharge; mRSf: Modified Rankin score at follow-up; GOS: Glascow outcome score; *: Artificial cranioplasty.

4

12 Focal seizure

– 2 3

4

720

288

Left

Right

4

6

4

9

Traffic accident

Traffic accident Female 156

Male 46

disease of newborn

3 210 Left 4 15 Late onset hemorrhagic 8

Female

14 Fall from height Female 23

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rs p

2

1 Wound infection 2

5* 5 – 4 157.5 Bilateral 7

2

4

12* 1

1.5 Hygroma

– 3

2 4 480

572

Right

Bilateral

1

1

3

3 Traffic accident

3

Table 2. The relation between mRS and age, decompression time, cranioplasty time, preoperative Glasgow Coma Scale, and decompression area mRS

Fall from height

Female

Female 20

14 Hit by rigid object Male 71

146

2 6 Meningitis 1 432 Bilateral 4

0

5* 3 Meningitis 4 160

Male

Traffic accident

2 792 Bilateral 1

2

2

0.5 3

Wound infection

3

0 3

Traffic accident

3

235

325

Right

Bilateral

2

1

6

3

Fall from height

Male

Female 13

180

14 2 – 0 1 229 Right 4 11 Fall from height Male 48

Age Gender Complaint (months)

Table 1. Demographic findings of the patients

Preoperative GCS

Decompression DC side time

Decompression mRSd mRSf Complication Cranioplasty Follow-up area (cm2) time (years)

Taşkapılıoğlu et al. Retrospective analysis of DC performed in pediatric patients with subdural hematoma

Shapiro Wilk test and median (minimum: maximum) values were used to express these variables. Categorical variables were expressed as n (%). The relation between mRS and age, decompression time, cranioplasty time, preoperative GCS, and decompression area findings were assessed using correlation analysis and Spearman correlation coefficient (rs) was computed (Table 2). SPSS (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.) was used for statistical analysis and the level of significance was set at α=0.05.

DISCUSSION Several authors have examined the usefulness of DC in children, but its role is still controversial. The indications and results of DC are unclear to date. There have only been a few studies that evaluated the clinical results of DC in pediatric patients.[8–12] Most of these studies had a limited number of patients and heterogeneous indications for DC. DC is indicated within 4 hours after the trauma or secondary clinical deterioration. DC is not recommended in patients with ICP maintained over 40 mmHg.[13] In the guidelines for the acute medical management of severe traumatic brain injury in infants, the treatment threshold for children and adolescents was considered when ICP was at 20 mmHg.[6] ICP monitoring kit was placed in 7 patients in our series but only 1 of these was preoperatively placed, while 6 were placed after DC for clinical follow-up. Mean ICP opening pressure for postoperative DC was 6 mmHg, representing the usefulness of decompression. It has been shown that there is a 60% mortality gap between the patients operated within 4 hours and more than 4 hours after injury.[14] However, there was no statistically significant relation was determined between mortality, morbidity, and time from injury to operative evacuation on an hourly basis.[15] Brain Trauma Foundation guidelines recommend DC in the first 48 hours after onset of ICP elevation[6] but there are 385


Taşkapılıoğlu et al. Retrospective analysis of DC performed in pediatric patients with subdural hematoma

many studies stating that early DC is considered to improve prognosis.[10,11] Kan et al.[16] presented a very high mortality rate with early DC performed after 6 hours from the time of the trauma, however, 23.5% of cases were due to nonaccidental trauma and the mean preoperative Glasgow Coma Scale (GCS) score was 4.6 in that series. Better outcomes might be achieved with earlier surgery but further prospective studies are needed to detect the best timing for surgery. Our mean preoperative time from admission to the operation was 3.18 hours, which supports the practice of earlier surgery. Several authors used different surgical techniques for the treatment of SDH. Bifrontal craniotomy with dural grafts, bitemporal craniectomy without dural opening, or unilateral frontotemporoparietal flaps with duraplasty can be used for DC. None of these techniques has proven to have better outcomes, however, dural opening reduces ICP significantly better than bone elevation alone.[17] We performed 5 bilateral DCs in this series and duraplasty was added to all DCs. The mortality rate has been detected to be lower than the nonsurgical group in two studies.[8,18] Low GCS score, fixed pupils, and severe damage on the CT scan are the factors that were associated with increased mortality.[19] There were 6 patients with a GCS ≤8 but there was no excitus in our series. That situation could be the result of very early intubation and sedation in the emergency room that can affect the real GCS of the patient. Aneed for a second surgery for cranioplasty is a handicap for DC. There are many techniques for preserving the bone flap including deep freezing, immersion in bactericidal solutions, subgaleal pouch preservation, abdominal pocket, or sterilization.[20] We kept the bone flaps at -19.5 °C in a deep freeze dedicated as the bone bank. Comparing to preservation of subgaleal pouch or abdominal pocket, the high rate of graft resorption is the biggest handicap of this storage technique and avoiding the second incision is the biggest priority. Hygroma and hydrocephalus are the most frequent complications of this surgery followed by infection and bone flap resorption. Sinking skin flap syndrome did not occur in our reviewed cases. Posttraumatic hydrocephalus after severe traumatic brain injury (TBI) was reported as 20%.[21] The high rate of complications reflects the severity of the disease. In contrast to the literature, there was only one subdural hygroma in our series (9.09%). There were 2 (18.1%) meningitis and 2 (18.1%) wound infections in our series but there was no correlation between these and the craniectomy size and time of surgery. Long-term follow-up examinations of previous studies revealed that 59% of the patients were completely independent where 5% of them were severely disabled.[10,11] In our series, all the survivors had a favorable long-term result. 386

Suárez et al.[19] stated that to demonstrate a 10% reduction in mortality of DC by 80%, a 294-patient clinical study should be performed. In an adult trauma series, Sedney et al.[22] mentioned that there was no relationship between craniectomy size and outcome, or complication rate. Their average craniectomy area was 124 cm2 which was far smaller than our average craniectomy size of 403.6 cm2, which was calculated by using the equation of De Bonis.[23] Studies focusing on the craniectomy size in TBI patients mentioned that there was an improved outcome with the larger craniectomy size and an increased complication rate,[24,25] while others pointed that smaller craniectomies (<180 cm2) are equally effective in relieving intracranial hypertension as the larger ones (≥180 cm2).[26] In our series, we did not find a correlation between higher complication rate and larger craniectomy size, which this may be due to the small sample size. The DECRA trial, one of the most effective studies of these days, showed that DC lowers the mortality while absolutely increasing the morbidity. However, this trial focused on diffuse intracranial hypertension and patients were excluded if they had dilated or unreactive pupils, surgically removable intracranial mass lesions, spinal cord injuries, or cardiac arrest at the scene of injury.[27] The pathology treated with DC in this study is completely different from the DECRA trial and that can be the cause of the differences between the two studies. Suárez et al.[19] mentioned that all the pediatric head injury patients in their series were evaluated as moderately disabled or independent at the 2-year follow-up. The mRS at the time of discharge was considered favorable in our series. Three of our patients were considered as moderately severe disable. The mean mRS changed from 2.8 to 1.6 at follow-up, which is similar to the literature. Cranioplasty is associated with high rates of bone resorption and surgical site infection in children.[28] In a very large retrospective study, Rocque et al.[28] concluded that younger age at cranioplasty is the dominant risk factor for bone resorption but there is no consensus about the time of cranioplasty. The mean cranioplasty time was 4.2 months. We used artificial cranioplasty material in 3 patients and in contradiction to the Rocque et al.,[28] our patients’ mean age was 109.6 months. The limited patient group is the main limitation of this study. In contrast to the adult group, we recommend early DC for pediatric subdural hematoma patients independent from initial GCS. In the future, we need larger studies to define the indications, surgical techniques, and timing of DC in the pediatric population. Conflict of interest: None declared. Ulus Travma Acil Cerrahi Derg, July 2019, Vol. 25, No. 4


Taşkapılıoğlu et al. Retrospective analysis of DC performed in pediatric patients with subdural hematoma

REFERENCES 1. Walker PA, Harting MT, Baumgartner JE, Fletcher S, Strobel N, Cox CS Jr. Modern approaches to pediatric brain injury therapy. J Trauma 2009;67:S120−7. 2. Langlois JA, Rutland-Brown W, Thomas KE. Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths. Atlanta, GA: Centers for Disease Control and Prevention, 2004. 3. Murray GD, Teasdale GM, Braakman R, Cohadon F, Dearden M, Iannotti F, et al. The European Brain Injury Consortium survey of head injuries. Acta Neurochir (Wien) 1999;141(:223−36. 4. Woertgen C, Rothoerl RD, Schebesch KM, Albert R. Comparison of craniotomy and craniectomy in patients with acute subdural haematoma. J Clin Neurosci 2006;13:718−21. 5. Li LM, Kolias AG, Guilfoyle MR, Timofeev I, Corteen EA, Pickard JD, et al. Outcome following evacuation of acute subdural haematomas: a comparison of craniotomy with decompressive craniectomy. Acta Neurochir (Wien) 2012;154:1555−61. 6. Kochanek PM, Carney N, Adelson PD, Ashwal S, Bell MJ, Bratton S, et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents--second edition. Pediatr Crit Care Med 2012;13:1−82. 7. Phan K, Moore JM, Griessenauer C, Dmytriw AA, Scherman DB, Sheik-Ali S, et al. Craniotomy Versus Decompressive Craniectomy for Acute Subdural Hematoma: Systematic Review and Meta-Analysis. World Neurosurg 2017;101:677−85. 8. Taylor A, Butt W, Rosenfeld J, Shann F, Ditchfield M, Lewis E, et al. A randomized trial of very early decompressive craniectomy in children with traumatic brain injury and sustained intracranial hypertension. Childs Nerv Syst 2001;17:154−62. 9. Hejazi N, Witzmann A, Fae P. Unilateral decompressive craniectomy for children with severe brain injury. Report of seven cases and review of the relevant literature. Eur J Pediatr 2002;161:99−104. 10. Ruf B, Heckmann M, Schroth I, Hügens-Penzel M, Reiss I, Borkhardt A, et al. Early decompressive craniectomy and duraplasty for refractory intracranial hypertension in children: results of a pilot study. Crit Care 2003;7:133−8. 11. Figaji AA, Fieggen AG, Peter JC. Early decompressive craniotomy in children with severe traumatic brain injury. Childs Nerv Syst 2003;19:666−73. 12. Rutigliano D, Egnor MR, Priebe CJ, McCormack JE, Strong N, Scriven RJ, et al. Decompressive craniectomy in pediatric patients with traumatic brain injury with intractable elevated intracranial pressure. J Pediatr Surg 2006;41:83−7. 13. Adelson PD, Bratton SL, Carney NA, Chesnut RM, du Coudray HE, Goldstein B, et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents. Chapter 15. Surgical treatment of pediatric intracranial hypertension. Pediatr Crit Care Med 2003;4:56−9. 14. Seelig JM, Becker DP, Miller JD, Greenberg RP, Ward JD, Choi SC. Trau-

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matic acute subdural hematoma: major mortality reduction in comatose patients treated within four hours. N Engl J Med 1981;304:1511−8. 15. Wilberger JE Jr, Harris M, Diamond DL. Acute subdural hematoma: morbidity, mortality, and operative timing. J Neurosurg 1991;74:212−8. 16. Kan P, Amini A, Hansen K, White GL Jr, Brockmeyer DL, Walker ML, et al. Outcomes after decompressive craniectomy for severe traumatic brain injury in children. J Neurosurg 2006;105:337−42. 17. Yoo DS, Kim DS, Cho KS, Huh PW, Park CK, Kang JK. Ventricular pressure monitoring during bilateral decompression with dural expansion. J Neurosurg 1999;91:953−9. 18. Josan VA, Sgouros S. Early decompressive craniectomy may be effective in the treatment of refractory intracranial hypertension after traumatic brain injury. Childs Nerv Syst 2006;22:1268−74. 19. Pérez Suárez E, Serrano González A, Pérez Díaz C, García Salido A, Martínez de Azagra Garde A, Casado Flores J. Decompressive craniectomy in 14 children with severe head injury: clinical results with longterm follow-up and review of the literature. J Trauma 2011;71:133−40. 20. Morina A, Kelmendi F, Morina Q, Dragusha S, Ahmeti F, Morina D, et al. Cranioplasty with subcutaneously preserved autologous bone grafts in abdominal wall-Experience with 75 cases in a post-war country Kosova. Surg Neurol Int 2011;2:72. 21. Marmarou A, Foda MA, Bandoh K, Yoshihara M, Yamamoto T, Tsuji O, et al. Posttraumatic ventriculomegaly: hydrocephalus or atrophy? A new approach for diagnosis using CSF dynamics. J Neurosurg 1996;85:1026−35. 22. Sedney CL, Julien T, Manon J, Wilson A. The effect of craniectomy size on mortality, outcome, and complications after decompressive craniectomy at a rural trauma center. J Neurosci Rural Pract 2014;5:212−7. 23. De Bonis P, Pompucci A, Mangiola A, Rigante L, Anile C. Post-traumatic hydrocephalus after decompressive craniectomy: an underestimated risk factor. J Neurotrauma 2010;27:1965−70. 24. Jiang JY, Xu W, Li WP, Xu WH, Zhang J, Bao YH, et al. Efficacy of standard trauma craniectomy for refractory intracranial hypertension with severe traumatic brain injury: a multicenter, prospective, randomized controlled study. J Neurotrauma 2005;22:623−8. 25. Qiu W, Guo C, Shen H, Chen K, Wen L, Huang H, et al. Effects of unilateral decompressive craniectomy on patients with unilateral acute post-traumatic brain swelling after severe traumatic brain injury. Crit Care 2009;13:185. 26. Tanrikulu L, Oez-Tanrikulu A, Weiss C, Scholz T, Schiefer J, Clusmann H, et al. The bigger, the better? About the size of decompressive hemicraniectomies. Clin Neurol Neurosurg 2015;135:15−21. 27. Cooper DJ, Rosenfeld JV, Murray L, Arabi YM, Davies AR, D’Urso P, et al. Decompressive craniectomy in diffuse traumatic brain injury. N Engl J Med 2011;364:1493−502. 28. Rocque BG, Agee BS, Thompson EM, Piedra M, Baird LC, Selden NR, et al. Complications following pediatric cranioplasty after decompressive craniectomy: a multicenter retrospective study. J Neurosurg Pediatr 2018;22:225−32.

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ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Akut subdural hematom nedeni ile pediyatrik yaş grubunda dekompresif kraniyektomi uygulanan hastaların geriye dönük analizi Dr. M. Özgür Taşkapılıoğlu,1 Dr. Ali İmran Özmarasalı,1 Dr. Gökhan Ocakoğlu2 1 2

Uludağ Üniversitesi Tıp Fakültesi, Beyin ve Sinir Cerrahisi Anabilim Dalı, Bursa Uludağ Üniversitesi Tıp Fakültesi, Biyoistatistik Anabilim Dalı, Bursa

AMAÇ: Dekompresif kraniyektominin (DK) pediyatrik subdural hematom hastalarındaki sonuca etkisi tam olarak belirlenmemiştir. Bu çalışmada pediyatrik yaş grubunda travmatik subdural hematom hastalarında DK rolünü araştırmayı amaçladık. GEREÇ VE YÖNTEM: Pediyatrik akut subdural hematom hastalarında DK deneyimimiz sonuç analizleri ile açıklandı. BULGULAR: On bir (7 tek taraflı ve 4 iki taraflı) DK uygulandı. Hastaların yaşları 8 ay ile 15 yaş arasında idi. Ortalama Glasgow koma skoru (GKS) başvuru anında 7.8 idi ve hastaların tümü ilk iki saat içinde duraplasti ile birlikte DK ameliyatına alındı. Tüm hastalar ameliyat sonrası dönemde 10 gün yoğun bakım ünitesinde izlendi. Hastaların ortalama hastanede kalış süreleri 22 gün ve ortalama takip süreleri 3.7 yıl idi. TARTIŞMA: Pediyatrik subdural hematom hastalarında erken DK hastaneye başvuru anındaki GKS’den bağımsız olarak yararlıdır. Pediyatrik yaş grubunda endikasyonlar, cerrahi teknik ve DK’nın zamanlaması için daha geniş hasta sayılı çalışmalara ihtiyaç vardır. Anahtar sözcükler: Akut subdural hematom; dekompresif kraniyektomi; kafa travması. Ulus Travma Acil Cerrahi Derg 2019;25(4):383-388

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doi: 10.5505/tjtes.2018.02403

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ORIG I N A L A R T IC L E

Effect of temporary vascular shunting as a previous intervention on lower extremity arterial injury: Single center experiences in the Syrian Civil War Ali İhsan Hasde, M.D.,1 Çağdaş Baran, M.D.,1 Fatih Gümüş, M.D.,1 Mahmut Kış, M.D.,2 Evren Özçınar, M.D.,1 Mehmet Çakıcı, M.D.,1 Levent Yazıcıoğlu, M.D.,1 Bülent Kaya, M.D.1 1

Department of Cardiovascular Surgery, Ankara University Faculty of Medicine, Ankara-Turkey

2

Depatment of Cardiovascular Surgery, Hatay State Hospital, Hatay-Turkey

ABSTRACT BACKGROUND: The goal of this retrospective study was to clarify the effect of using temporary vascular shunt (TVS) as a previous intervention. METHODS: A total of 96 cases with war-related lower extremity arterial injury and surgically treated between October 2013 and March 2016 were included in the study. The patients were divided into two groups: those in which TVS was performed as a previous intervention on admission (TVS group, n=24) and those in which compression, tourniquet, and ligation/clampage were performed as a previous intervention on admission (non-TVS group, n=72). RESULTS: In comparing injury pattern, there was no difference between the two groups. In addition, mean hematocrit level, mean systolic blood pressure, the incidence of concomitant vein injury, nerve injury, soft tissue damage, and bone injury were similar in both groups. The overall amputation rate was 19%. There were a total of 18 amputations, with 1 (4%) in the TVS group and 17 (24%) in the non-TVS group. The difference on amputation rate was statistically significant. The mean values of the mangled extremity severity score (MESS) were 6.45 in the TVS group and 7.44 in the non-TVS group. The overall mean MESS was 7.1. The duration of ischemia (DoI) was 4.84±1.84 h in the TVS group and 5.95±1.92 h in the non-TVS group. These differences in MESS and DoI were statistically significant. CONCLUSION: We think that it may be beneficial for patients to consider a TVS to reduce DoI and gain time for surgical revascularization. As a result, the present study demonstrates that the use of TVS may successfully serve as a bridge between initial injury and definitive repair with a reduction in amputation rates. Keywords: Amputation; arterial injuries; temporary vascular shunt; war.

INTRODUCTION War leads to disastrous results for both military personnel and civilians. Vascular lesions appear in approximately 10% of war-related injuries with extremity injuries accounting for 75% of this amount.[1] Osseous, nerve, vein, and soft tissue injuries may be concomitant with arterial injuries. The management of war-related extremity injuries is chal-

lenging; if not properly managed, these injuries may result in such significant outcomes as limb loss or death.[2] Vascular injuries sustained during both World War I and II were routinely managed with simple ligation.[3] The approach and timing of vascular repair in patients with complex extremity injuries can prove difficult and time consuming. In 1971, Eger et al.[4] were among the first to describe the use of a temporary vascular shunt (TVS) for a popliteal artery injury

Cite this article as: Hasde Aİ, Baran Ç, Gümüş F, Kış M, Özçınar E, Çakıcı M, et al. Effect of temporary vascular shunting as a previous intervention on lower extremity arterial injury: Single center experiences in the Syrian Civil War. Ulus Travma Acil Cerrahi Derg 2019;25:389-395. Address for correspondence: Ali İhsan Hasde, M.D. Ankara Üniversitesi Tıp Fakültesi, Kalp ve Damar Cerrahisi Anabilim Dalı, Ankara, Turkey Tel: +90 312 - 595 60 84 E-mail: ahasde@gmail.com Ulus Travma Acil Cerrahi Derg 2019;25(4):389-395 DOI: 10.5505/tjtes.2018.29302 Submitted: 24.09.2018 Accepted: 23.11.2018 Online: 08.07.2019 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

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Hasde et al. Effect of temporary vascular shunting as a previous intervention on lower extremity arterial injury

temporarily restoring perfusion to an injured limb while bone fracture fixation occurred. TVSs have since been used and are well described in the civilian literature as an adjunct for the treatment of peripheral vascular injuries.[5â&#x20AC;&#x201C;8] The goal of this retrospective study was to clarify the effect of TVS as a previous intervention in cases of war-related arterial injuries.

MATERIALS AND METHODS

Table 1. Mangled extremity severity score Variables Score Skeletal/soft tissue injury

Low energy (stab, simple fracture, pistol

gunshot wounds)

Medium energy (open or multiple fractures,

dislocation)

wound)

In this retrospective study, data were collected from the medical records of Hatay State Hospital, Hatay, Turkey. One hundred two patients with lower extremity arterial injuries suffered during the Syrian Civil War between October 2013 and March 2016 were evaluated. Six patients on whom primary amputation had already been performed without any surgical vascular intervention were excluded from the study. The decision for primary amputation in these cases had been decided by a cardiovascular surgeon, an orthopedist, and a plastic surgeon based on medical experience, viability of the injured extremity, life-threatening condition, massive tissue loss, gross contamination, and mangled extremity severity score (MESS) (Table 1). All patients had had a previous intervention at the battle site, including compression (n=34, 35%), TVS (n=24, 25%), tourniquet (n=20, 21%), and ligation/ clampage (n=18, 19%) and were then admitted to our center (Table 2). Ninety-six patients were divided into two groups: those in which TVS was performed as a previous intervention on admission (TVS group, n=24) and those in which compression, tourniquet, and ligation/clampage were performed as a previous intervention on admission (non-TVS group, n=72). The individual medical records were reviewed to analyze the following variables: age, gender, mechanism of injury, clinical findings, MESS, duration of ischemia (DoI), concomitant injuries, surgical procedures and interventions, wound infection, rate of amputation, and mortality (Table 3). First, the patients were evaluated in the emergency services. The evaluation of the arterial injury was mostly undertaken by physical examination. Indications for vascular surgical intervention were defined as follows: signs of leg ischemia, reduced or absent distal pulse, arterial bleeding, expanding hematoma, pulsatile hematoma, the presence of thrill or murmur, and performing definitive repair at the injury site. Primary endpoints were MESS, DoI, and rate of amputation.

Operative exploration of these cases varied. In cases of injuries caused by bullets, exploration was performed according to standard arterial exposure. In patients with severe tissue loss due to explosive devices and following hemodynamic stabilization and wound decontamination, exploration was conducted to expose and repair vascular structure as soon as proven possible. Arterial injuries were repaired prior 390

2

High energy (high speed MVA or rifle gunshot

Study Design and Patients

Surgical Management

1

3

Very high energy (high speed trauma+gross

contamination)

4

Limb ischemia

Pulse reduced or absent but perfusion normal

1a

Pulseless, paresthesias, diminished capillary refill

2a

Coll, paralyzed, insensate, numb

3a

Shock

Systolic blood pressure always >90 mmHg

1

Hypotensive transiently

2

Persistent hypotension

3

Age (years) <30

1

30â&#x20AC;&#x201C;50

2

>50

3

Score doubled for ischemia >6 h. MVA: Motor vehicle accident.

a

Table 2. Distributions of previous interventions on admission Previous intervention

n=96 n

%

Compression

34 35

Temporary vascular shunt

24

Tourniquet

20 21

Ligation/clampage

18 19

25

to bone, nerve, and tendon repair. Thereafter, clamping to the proximal and distal sides of the site of injury was conducted. In patients in the TVS group, shunts were removed after clamping. Systemic heparinization was performed except for a great deal of soft tissue and muscle destruction. Fogarty catheters were routinely used proximally and distally to remove any thrombus. Primary repair or end to end anastomosis was preferred, but where it was not possible, the greater saphenous vein of an uninjured leg or polytetrafluoroethylene graft was used for interposition graft. Polypropylene sutures were used for anastomosis. Concomitant vein injuries were repaired whenever possible. All patients with associated orthopedic injuries underwent reduction of bone Ulus Travma Acil Cerrahi Derg, July 2019, Vol. 25, No. 4


Hasde et al. Effect of temporary vascular shunting as a previous intervention on lower extremity arterial injury

Table 3. Demographics, features of injuries, and findings of patients

Overall (n=96)

TVS group (n=24)

Non TVS group (n=72)

p (p<0.05)

Age, mean±SD

28.32±10.16

28.04±10.06

28.41±10.33

0.87a

Gender (male)

91 (95)

22 (92)

69 (96)

0.59b 0.25b

Injury mechanism, n (%)

Gunshot

46 (48)

14 (58)

32 (44)

Explosive

50 (52)

10 (42)

40 (56)

Clinical findings on admission

Hematocrit (%), mean±SD

29.12±4.24

29.85±3.63

28.7±4.48

0.25a

Systolic blood pressure (mmHg), mean±SD

92.47±9.1

94.9±9.24

91.6±8.81

0.08a

Injured vascular structure, n (%)

Arterial

49 (51)

13 (54)

36 (50)

0.81b

Arterial and vein

47 (49)

11 (46)

36 (50)

0.81b

Bone fracture, n (%)

37 (39)

8 (33)

29 (40)

0.63b

Major soft tissue disruption, n (%)

39 (41)

11 (39)

28 (46)

0.63b

Major nerve injury, n (%)

26 (27)

8 (33)

18 (25)

0.43b

Mangled extremity severity score, mean±SD

7.17±1.75

6.45±1.67

7.44±1.82

0.02a

Duration of ischemia, mean±SD

5.37±1.91

4.84±1.84

5.95±1.92

0.016a

Fasciotomy, n (%)

40 (42)

7 (29)

33 (46)

0.23b

Wound infection, n (%)

25 (26)

5 (21)

20 (28)

0.59b

Amputation, n (%)

18 (19)

1 (4)

17 (24)

0.037b

0 (0)

0 (0)

0 (0)

1.00

Mortality, n (%)

Student’s t-test, bFisher’s exact test. TVS: Temporary vascular shunt; SD: Standard deviation.

a

fracture and immobilization by internal or external fixation. Concomitant soft tissue, tendon, and most nerve injuries were repaired at the same time. After revascularization, fasciotomy was performed therapeutically if compartment syndrome (the compression of nerves, blood vessels, and muscle inside a closed space or compartment, leading to tissue death from the lack of oxygenation as a consequence of the increased pressure within the compartment) developed on admission and prophylactically in case of preoperative pulse deficit with ischemic time >6 h and/or with major soft tissue disruption. In the postoperative period, low molecular weight heparin was used for all patients. The decision for secondary amputation was decided after surgical intervention in the event of weak/faint pulse, coldness of extremity, massive soft tissue loss, existing massive infection, or other life-threatening condition.

Statistical Analysis Statistical analysis was performed using SPSS version 16.0 for Windows (SPSS Inc., Chicago, IL, USA). Mean and standard deviation were calculated for continuous variables. Descriptive data were compared by Student’s t-test for means. For comparison of qualitative data, the Pearson chi-square test with Yate’s correction or Fisher’s exact test was used. A p value of <0.05 was considered as significant. Ulus Travma Acil Cerrahi Derg, July 2019, Vol. 25, No. 4

RESULTS One hundred two cases with war-related arterial injury were transferred to the emergency services, and overall amputation rate (primary and secondary) was 23% (24 of 102 patients). Six cases on whom primary amputation had been performed were excluded from the study. On admission, we realized that some form of intervention (compression, TVS, tourniquet, or ligation/clampage) had been applied to all patients at a different first aid center/health institution near the battle sites. Ninety-six patients were divided into two groups: those in which TVS was performed as a previous intervention on admission (TVS group, n=24) and those in which compression, tourniquet, and ligation/clampage were performed as a previous intervention on admission (non-TVS group, n=72) (Table 2). Table 3 demonstrates the patient demographics with respect to average age, gender, mechanism of injury, clinical findings, concomitant pathologies, MESS, DoI, and amputations. The study comprised 91 (95%) male patients, with 22 (92%) in the TVS group and 69 (96%) in the non-TVS group. The mean age of the patients was 28.3 (13–57) years (Table 3). In comparing injury pattern, there was no difference between the two groups. In addition, mean hematocrit level, mean 391


Hasde et al. Effect of temporary vascular shunting as a previous intervention on lower extremity arterial injury

Table 4. Distributions of arterial injuries and types of surgical procedures

Overall (n=118)

TVS group (n=26)

Non TVS group (n=92)

p (p<0.05)

Artery injured, n (%)

Femoral arteries

45 (38)

12 (46)

33 (36)

0.36

Popliteal artery

37 (31)

9 (35)

28 (30)

0.81

Crural arteries

36 (31)

5 (19)

31 (34)

0.23

Arterial procedure, n (%)

End to end anastomosis

40 (34)

9 (35)

31 (34)

1.00

Saphenous vein interposition

55 (47)

13 (50)

42 (46)

0.82

Polytetraflouroethylene

0.77

Vein injuries a

Vein repair, n (%)

23 (19)

4 (15)

19 (20)

n=61 (%)

n=20 (%)

n=41 (%)

46 (75)

14 (70)

32 (78)

0.53

Fisher’s exact test. TVS: Temporary vascular shunt.

systolic blood pressure, the incidence of concomitant vein injury, nerve injury, soft tissue damage, and bone injury were similar in both groups (Table 3).

ment syndrome. Among these patients, secondary amputation was performed on 13 (33%) patients (1 patient in the TVS group and 12 patients in the non-TVS group).

The overall amputation rate was 19%. There were a total of 18 amputations, with 1 (4%) in the TVS group and 17 (24%) in the non-TVS group. The difference on amputation rate was statistically significant.

The overall wound infection rate was 26% (25 patients, with 5 patients in the TVS group and 20 patients in the non-TVS group). Infectious agents were Staphylococcus aureus in 12 cases, Acinetobacter baumannii in 5, Pseudomonas aeruginosa in 3, Escherichia coli in 2, Citrobacter koseri in 1, Cedecea lapagei in 1, and Staphylococcus gallinarum in 1.

The mean values of the MESS were 6.45 in the TVS group and 7.44 in the non-TVS group. The overall mean MESS was 7.1. The DoI was 4.84±1.84 h in the TVS group and 5.95±1.92 h in the non-TVS group. These differences in MESS and DoI were statistically significant. There were 118 arteries and 61 veins injured in the 96 cases. Combined artery and vein injuries were determined in 47 patients. All arteries and 46 of 61 veins were repaired (15 calf veins were ligated). The injured vascular structures and the surgical procedures performed are compiled in Table 4 (Fig. 1a-c). Fasciotomy was performed on 40 (42%) patients who had combined artery and vein injuries, DoI >6 h, and compart-

(a)

(b)

The etiology of the amputation was graft thrombosis in 11 (61%) cases, wound infection leading to sepsis in 4 (22%) cases, and extensive soft tissue loss in 3 (17%) cases. There was no mortality in the hospital.

DISCUSSION War-related arterial injuries are a challenge to manage and may result in different ways, from simple injuries caused by low energy basic devices to complex injuries caused by high energy explosive and destructive devices.[1–3,9,10] We are now regularly encountering these kinds of injuries due to the Syrian Civil War in parallel to the literature. The hospital where the injured people are treated is located in Hatay,

(c)

Figure 1. (a) Repair of popliteal artery and vein with saphenous vein interposition. (b) Proximal side of femoral artery and vein, after resection of injured side. (c) Repair of femoral artery and vein with polytetrafluoroethylene graft interposition.

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near the border with Syria in southernmost Turkey. There are some difficulties, and especially constraints, in making diagnoses because the hospital is only a level 2 civil healthcare institution, so it has no advanced technical facilities. In the main, patients were diagnosed by physical examination, whereas computed tomography angiography, the gold standard method for diagnosis, and Doppler ultrasonography were rarely used (Fig. 2).[1] In previous years, most war-related injuries encountered were shooting injuries, but following the Iraq and Afghanistan wars, it was realized that the majority of such injuries were now caused by high powered and destructive weapons developed in parallel with advancements in technology.[11] We have subsequently seen even bigger and more complex injuries in the Syrian Civil War. The first patient interventions had been done by local healthcare teams in places near to the different war areas. After medical or surgical intervention, the patients were transferred away from the border and brought to our healthcare institution by a Turkish emergency team. An urgent first intervention has quite an important effect in precluding amputation. Most of the wounds seen in the early stages of the war were initially treated by compression, tourniquet, and ligation/clamping. However, in the main, a TVS had been applied to patients who were brought in during the later periods of the war by the first intervention team. The aim of our study was to analyze the effect of TVS after extremity vascular injury. The protection of vital organs and the use of tourniquets in the field have led to an increase in the number of patients presenting to military treatment facilities with extremity and peripheral vascular injuries. In addition, strategically placed forward surgical capability allows for earlier extremity vascular injury assessment. The use of TVSs has emerged as a viable treatment option for military

Figure 2. Image of computed tomography angiography.

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surgeons in the forward operating arena and has proven successful for hemorrhage control, shorter ischemia time, and temporary limb perfusion.[12] Temporary vascular shunting is a method of timely restoration of flow and is well described in settings of damage control in both the military and civilian sectors. Seemingly important during times of hemodynamic instability, re-warming, and acid–base correction, shunts have also been used during extremity stabilization after initial injury exploration.[4,13,14] Rush et al.[15] expressed that ischemia duration is the most important factor related to amputation independent from MESS. Consistent with the literature, femoral artery injuries were the most commonly injured arterial structures in our study and comprise almost 38% of all arterial traumas compared in the recent series.[16] Regarding the management of vascular injuries, reversed saphenous vein was the most commonly preferred and used graft in repair for our series in accordance with the literature.[17] In many studies, fasciotomy and vein repair are recommended especially in patients who have combined arterial and venous insufficiency, have DoI >6 h, or where bone and soft tissue trauma associated with vascular injury and compartmental pressures have risen seriously.[18,19] Clouse et al.[18] emphasized that a venous injury associated with an arterial injury is seen in all of the early amputated patients in their study. Gifford et al.[20] reported that the rate of fasciotomy they performed in their patients is 63%, but the rate of secondary amputation is lower at 14%. In our study, combined arterial and vein injuries, rate of vein repair, and performing fasciotomy were similar in both groups. Many scoring systems that aid in the amputation decision in cases of serious lower extremity injuries have so far been defined.[21] The MESS described by Johansen was used to determine the viability of an extremity after trauma. According to the author, when the score is <7, limb-salvage can be performed; if it is >7, amputation is recommended. The MESS was determined upon admission.[22] MESS is one of these scoring systems, providing an idea of the viability of an extremity after trauma and whether to undergo amputation. Brown et al.[23] reported that the extremity is preserved in 35.7% of the patients whose MESS is ≥7, although this score in fact indicates a high probability of amputation. Şişli et al.[24] found in their study that the extremity is kept in 60% of patients who have MESS >7, and that the MESS scoring system is not in itself a sufficient criterion to determine amputation. In our study, MESS was used as a scoring system, and revascularization was performed despite the fact that 51 (53%) of 96 patients had MESS ≥7. Secondary amputation was applied to 18 (35%) of these patients. In our study, MESS was lower statistically different in favor of the TVS group (6.45±1.67 vs. 7.44±1.82) (p<0.05). This may be explained by shorter DoI in patients in the TVS group. Performing a TVS provides urgent and effective control of bleeding and sufficient distal perfusion after major vascular 393


Hasde et al. Effect of temporary vascular shunting as a previous intervention on lower extremity arterial injury

injury. Barros et al.[25] showed that amputation rate decreases from 32.4% to 39.5% and from 8.8% to 14.3% in patients where a TVS was performed. In our study, DoI and amputation rates were significantly lower in favor of the TVS group (p<0.05). In the current study, we emphasize being able to perform a TVS as the first intervention is really important in enabling patients with lower extremity arterial injuries to keep those extremities because it provides time to surgeons to cope with the negative effects of ischemia and undertake bleeding control and revascularization. In conclusion, the aim of the present study was to analyze the effect of using TVS as a previous intervention. We think that it may be beneficial for patients to consider a TVS to reduce DoI and gain time for surgical revascularization. As a result, the present study demonstrates that the use of TVS may successfully serve as a bridge between initial injury and definitive repair with a reduction in amputation rates. Conflict of interest: None declared.

REFERENCES 1. Fox CJ, Patel B, Clouse WD. Update on wartime vascular injury. Perspect Vasc Surg Endovasc Ther 2011;23:13−25. 2. Weaver FA, Papanicolaou G, Yellin AE. Difficult peripheral vascular injuries. Surg Clin North Am 1996;76:843−59. 3. DeBakey ME, Simeone FA. Battle injuries of the arteries in World War II; an analysis of 2,471 cases. Ann Surg 1946;123:534−79. 4. Eger M, Golcman L, Goldstein A, Hirsch M. The use of a temporary shunt in the management of arterial vascular injuries. Surg Gynecol Obstet 1971;132:67−70. 5. Barros D’Sa AA, Moorehead RJ. Combined arterial and venous intraluminal shunting in major trauma of the lower limb. Eur J Vasc Surg 1989;3:577−81. 6. Nalbandian MM, Maldonado TS, Cushman J, Jacobowitz GJ, Lamparello PJ, Riles TS. Successful limb reperfusion using prolonged intravascular shunting in a case of an unstable trauma patient--a case report. Vasc Endovascular Surg 2004;38:375−9. 7. Davins M, Llagostera S, Lamas C, López S. Role of temporary arterial shunt in the reimplantation of a traumatic above-elbow amputation. Vascular 2007;15:176−8. 8. Nunley JA, Koman LA, Urbaniak JR. Arterial shunting as an adjunct to major limb revascularization. Ann Surg 1981;193:271−3. 9. Davidovic LB, Cinara IS, Ille T, Kostic DM, Dragas MV, Markovic DM. Civil and war peripheral arterial trauma: review of risk factors associated with limb loss. Vascular 2005;13:141−7. 10. Haddock NT, Weichman KE, Reformat DD, Kligman BE, Levine JP, Saadeh PB. Lower extremity arterial injury patterns and reconstructive outcomes in patients with severe lower extremity trauma: a 26-year re-

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view. J Am Coll Surg 2010;210:66−2. 11. Eskridge SL, Macera CA, Galarneau MR, Holbrook TL, Woodruff SI, MacGregor AJ, et al. Injuries from combat explosions in Iraq: injury type, location, and severity. Injury 2012;43:1678−82. 12. Taller J, Kamdar JP, Greene JA, Morgan RA, Blankenship CL, Dabrowski P, et al. Temporary vascular shunts as initial treatment of proximal extremity vascular injuries during combat operations: the new standard of care at Echelon II facilities? J Trauma 2008;65:595−603. 13. Chambers LW, Green DJ, Sample K, Gillingham BL, Rhee P, Brown C, et al. Tactical surgical intervention with temporary shunting of peripheral vascular trauma sustained during Operation Iraqi Freedom: one unit’s experience. J Trauma 2006;61:824−30. 14. Rasmussen TE, Clouse WD, Jenkins DH, Peck MA, Eliason JL, Smith DL. The use of temporary vascular shunts as a damage control adjunct in the management of wartime vascular injury. J Trauma 2006;61:8−12. 15. Rush RM Jr, Kjorstad R, Starnes BW, Arrington E, Devine JD, Andersen CA. Application of the Mangled Extremity Severity Score in a combat setting. Mil Med 2007;172:777−81. 16. Prichayudh S, Verananvattna A, Sriussadaporn S, Sriussadaporn S, Kritayakirana K, Pak-art R, et al. Management of upper extremity vascular injury: outcome related to the Mangled Extremity Severity Score. World J Surg 2009;33:857−63. 17. Carrillo EH, Spain DA, Miller FB, Richardson JD. Femoral vessel injuries. Surg Clin North Am 2002;82:49−65. 18. Clouse WD, Rasmussen TE, Peck MA, Eliason JL, Cox MW, Bowser AN, et al. In-theater management of vascular injury: 2 years of the Balad Vascular Registry. J Am Coll Surg 2007;204:625−32. 19. Dua A, Patel B, Desai SS, Holcomb JB, Wade CE, Coogan S, et al. Comparison of military and civilian popliteal artery trauma outcomes. J Vasc Surg 2014;59:1628−32. 20. Gifford SM, Aidinian G, Clouse WD, Fox CJ, Porras CA, Jones WT, et al. Effect of temporary shunting on extremity vascular injury: an outcome analysis from the Global War on Terror vascular injury initiative. J Vasc Surg 2009;50:549−55. 21. Krettek C, Seekamp A, Köntopp H, Tscherne H. Hannover Fracture Scale ‘98--re-evaluation and new perspectives of an established extremity salvage score. Injury 2001;32:317−28. 22. Johansen K, Daines M, Howey T, Helfet D, Hansen ST Jr. Objective criteria accurately predict amputation following lower extremity trauma. J Trauma 1990;30:568−72. 23. Brown KV, Ramasamy A, McLeod J, Stapley S, Clasper JC. Predicting the need for early amputation in ballistic mangled extremity injuries. J Trauma 2009;66:S93−7. 24. Şişli E, Kavala AA, Mavi M, Sarıosmanoğlu ON, Oto Ö. Single centre experience of combat-related vascular injury in victims of Syrian conflict: Retrospective evaluation of risk factors associated with amputation. Injury 2016;47:1945−50. 25. Barros D’Sa AA, Harkin DW, Blair PH, Hood JM, McIlrath E. The Belfast approach to managing complex lower limb vascular injuries. Eur J Vasc Endovasc Surg 2006;32:246−56.

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ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Alt ekstremite arteriyel yaralanmalarında ilk müdahalede geçici vasküler şant uygulamasının etkileri: Suriye iç savaşında tek merkez deneyimleri Dr. Ali İhsan Hasde,1 Dr. Çağdaş Baran,1 Dr. Fatih Gümüş,1 Dr. Mahmut Kış,2 Dr. Evren Özçınar,1 Dr. Mehmet Çakıcı,1 Dr. Levent Yazıcıoğlu,1 Dr. Bülent Kaya1 1 2

Ankara Üniversitesi Tıp Fakültesi, Kalp ve Damar Cerrahisi Anabilim Dalı, Ankara Hatay Devlet Hastanesi, Kalp ve Damar Cerrahisi Kliniği, Hatay

AMAÇ: Bu geriye dönük çalışmanın amacı, ateşli silah yaralanmalarında ilk müdahelede geçici vasküler şant (GVŞ) uygulamasının etkilerini irdelemektir. GEREÇ VE YÖNTEM: Ekim 2013 ve Mart 2016 tarihleri arasında ateşli silah yaralanması nedeniyle ameliyat edilen 96 hasta çalışmaya alındı. Hastalar; ilk girişim olarak GVŞ uygulanan hastalar (GVŞ grubu, n=24) ve ilk girişim olarak kompresyon, turnike ve ligasyon/klempaj uygulanan hastalar (GVŞ yapılmayan grup, n=72) olmak üzere iki gruba ayrıldı. BULGULAR: Yaralanma mekanizması karşılaştırıldığında, her iki grup arasında fark yoktu. Aynı şekilde ortalama hematokrit seviyesi, ortalama sistolik kan basıncı, eşlik eden ven ile sinir ve yumuşak doku ve kemik yaralanmaları her iki grupta benzerdi. Tüm ampütasyon oranı %19 idi. Biri GVŞ grubunda, 17’si diğer GVŞ yapılmayan hasta grubunda olmak üzere toplam ampütasyon sayısı 18 idi. Ortalama travmaya uğramış ekstremite skoru (MESS) GVŞ grubunda 6.45 iken GVŞ yapılmayan grupta 7.44 idi. İskemi süresi GVŞ grupta 4.84±1.84 saat iken GVŞ yapılmayan grupta 5.95±1.92 saat idi. MESS ve iskemi süresindeki farklılık istatistiksel olarak anlamlı değerlendirildi. TARTIŞMA: Geçici vasküler şant kullanımının iskemi süresini kısaltmak ve cerrahi revaskülarizayon için zaman kazandırması bakımından hastalar için faydalı olabileceğini düşünmekteyiz. Sonuç olarak, bu çalışma GVŞ kullanımının yaralanma başlangıcından nihai cerrahi onarımına kadar başarılı bir köprü görevi gördüğünü ve ampütasyon oranını azalttığını göstermektedir. Anahtar sözcükler: Ampütasyon; arteriyel yaralanma; geçici vasküler şant; savaş. Ulus Travma Acil Cerrahi Derg 2019;25(4):389-395

doi: 10.5505/tjtes.2018.29302

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ORIG I N A L A R T IC L E

Effectiveness of conservative approach in right colon diverticulitis Sabahattin Destek, M.D.,1

Vahit Onur Gül, M.D.2

1

Department of General Surgery, Bezmiâlem Vakif University Faculty of Medicine Hospital, İstanbul-Turkey

2

Department of General Surgery, Gulhane Training and Research Hospital, Ankara-Turkey

ABSTRACT BACKGROUND: Approximately 10%–25% of patients with colon diverticular disease experience colonic diverticulitis during their lives. Right-sided diverticulosis is a rare condition in Western countries, but it is common among Asian countries. The aim of this study was to evaluate the clinical and treatment outcomes in our patients with right colon diverticulitis. METHODS: Demographic and clinical data of 22 patients with a diagnosis of cecum and right-sided colon diverticulitis between 2014 and 2017 were analyzed. The Hinchey staging was applied according to the radiological evaluation and clinical findings. Then, the proportions of demographic and clinical features of the patients according to the Hinchey staging and its statistical significance were evaluated. RESULTS: Our study included 22 patients who suffered from right colon diverticulitis. The female-to-male ratio was 0.69. A total of 68.1% of the patients were the Hinchey Stage I, and 31.8% were the Hinchey Stage II, all of which were evaluated by tomography. The Hinchey Stage I diverticulitis was mostly found in the right colon (66.7%) and the Hinchey Stage II diverticulitis in the cecum (57.1%). The mean age of the Hinchey Stage II patients was higher (63.6 years) and statistically significant (p<0.05). Two patients had appendectomy, and one had right hemicolectomy. Conservative treatment was applied to other 19 patients. The mean hospitalization time was 3.4 days. Four patients who received conservative treatment at the 2-year follow-up had recurrence. No recurrence was observed in patients receiving surgical treatment. CONCLUSION: Right colon diverticulitis is usually seen in solitary men aged <50 years from Eastern societies. As a treatment option, conservative methods should be preferred, especially in uncomplicated cases. Surgical treatment is usually used in the treatment of recurrent and complicated cases. Keywords: Conservative treatment; Hinchey staging; right colon diverticulitis.

INTRODUCTION In the case of colonic diverticula, the colon mucosa is dislodged in the form of an outward pouch. The cases in which more than one diverticulum exists are called diverticulosis coli.[1] Colonic diverticular disease (CDD) was first defined by Cruvelhier in 1849.[1] The prevalence of CDD is 5%–45% in the Western societies.[2] It usually occurs after 50 years of age and is located in the leftsigmoid colon in 95% of the cases.[1,2] In approximately 1.5%

of the cases, it is located in the right colon.[1,2] The prevalence of CDD is 0.2% in Asia and 0.2% in Africa.[1] It usually occurs before 50 years of age, and in 70% of the cases, it is found in the right colon.[1–3] Diverticulitis is the most common CDD complication, and it occurs in 15%–25% of the cases.[1,2] Right colon diverticulitis (RCD) is usually solitary and congenital.[4] RCD generally occurs in middle-aged men, and its incidence does not increase with age.[5] It is difficult to distinguish RCD from acute appendicitis because of their similar symptoms and signs.

Cite this article as: Destek S, Gül VO. Effectiveness of conservative approach in right colon diverticulitis. Ulus Travma Acil Cerrahi Derg 2019;25:396-402. Address for correspondence: Sabahattin Destek, M.D. Bezmiâlem Vakıf Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İstanbul, Turkey Tel: +90 216 - 444 25 99 E-mail: sebahattindestek@yahoo.com Ulus Travma Acil Cerrahi Derg 2019;25(4):396-402 DOI: 10.14744/tjtes.2019.47382 Submitted: 26.10.2018 Accepted: 18.03.2019 Online: 08.07.2019 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

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Destek et al. Effectiveness of conservative approach in right colon diverticulitis

The aim of the present study was to evaluate the patients with RCD using clinical, laboratory, imaging, and treatment methods in one center. The efficacy of conservative treatment in RCD was evaluated.

MATERIALS AND METHODS Patients with RCD among patients with colon diverticulitis followed in the Department of General Surgery between 2011 and 2015 were retrospectively reviewed. In the present study, it was found that 152 patients received treatment for CDD. The patients without RCD, those who had additional pathologies such as colon tumor, those who were pregnant, and those with incomplete data were excluded from the study. Patients diagnosed as having RCD after the operation with a preliminary diagnosis of appendicitis were included in the study. Twenty-two cases with RCD meeting the inclusion criteria were detected. Age, gender, symptoms, the symptom duration, laboratory results, radiological findings, and treatments of patients were retrospectively analyzed. A body temperature >38.2°C at the time of admission was defined as fever. Blood tests were performed to determine the white blood cell count (upper limit of normal >10 ×103 μL) and the level of C-reactive protein (CRP) (upper limit of normal >0.5 mg/ dL). All patients underwent abdominal ultrasonography and oral and intravenous tomography. Patients were categorized according to the Hinchey classification by evaluating their radiological imaging features (Fig. 1).[2,6] The conservative and surgical treatment status of the patients was determined. Patients who were not operated and underwent drainage catheterization were evaluated under conservative treatment. By examining the medical records of the discharged patients and taking the information by telephone, we questioned whether the symptoms of diverticulitis recurred after discharge or whether the patient had an operation later.

Statistical Analysis

and the Mann–Whitney U test was used for variables not normally distributed. The chi-squared analysis was used to examine the correlations between the groups of nominal variables. Fisher’s exact test was used when the expected values in the tables did not have a sufficient volume, and Pearson’s chi-squared analysis was applied using the Monte Carlo simulation in cross-classified RxC tables. A significance level of 0.05 was used, indicating that there was a significant dependence between the groups when p<0.05, and no significant dependence between the groups when p>0.05.

RESULTS Twenty-two patients with RCD were included in the study. Nine (40.9%) were female, 13 (59%) were male, and the female-to-male (f/m) ratio was 0.69. The age range was 26–84, years, and the mean age of the patients was 50.9 years. The duration of the symptom prior to hospitalization was 1–5 days, with a mean of 2.36 days. In general, 59% of the patients had fever, 54.5% had nausea, 36.3% had diarrhea, 54.5% had pain in the right lower abdomen, and 45.4% had generalized abdominal pain at the time of admission. Leukocytosis was detected in 77.2% of all patients. High CRP levels were found in all patients (100%). Abdominal tomography was performed in all patients after oral, rectal, and intravenous contrast administration. Based on the localization, 59% of the patients had diverticulitis in the right colon, and 41% of them had diverticulitis in the cecum. The grade and stage of the acute diverticulitis were determined based on the findings of abdominal tomography. Accordingly, 68.1% of patients with localized pericolonic abscess or phlegmon with a diameter <5 cm were classified as the Hinchey Stage I, and 31.8% of patients with pelvic, intraabdominal, retroperitoneal abscess, >5 cm in diameter, but limited, were evaluated as the Hinchey Stage II diverticulitis. The Hinchey Stage I diverticulitis was detected mostly in the right colon (66.7%), and the Hinchey Stage II diverticulitis (57.1%) in the cecum (Fig. 2).

Data obtained in this study were evaluated using the SPSS 20.0 package software (IBM, Chicago). The frequency and percentage distributions of the data are presented. Differences between the groups were assessed by normality tests,

When the age of the patients with RCD was compared according to the Hinchey stages, the mean age of the patients with the Hinchey Stage II was higher (63.57 years), and this was statistically significant (p<0.05). The female-to-male ratio of the patients with RCD was 0.69, but the gender status

(a)

(c)

(b)

(d)

Figure 1. Hinchey Stage I (a and b) – II (c and d) Right colon diverticulitis on tomography.

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Destek et al. Effectiveness of conservative approach in right colon diverticulitis

Table 1. Demographic and clinical characteristics of patients with right colon diverticulitis Parameters

Hinchey Stage I

Hinchey Stage II

Results

n % Mean n % Mean Value p

Age (years)

15

45.7

7

63.57

2.507

0.012¥

Gender Male

10 66.7 – 3 42.9 – 1.068 0.376*

Female

5 33.3 – 4 57.1 –

Fever (>38.2 °C) Yes

7 46.7 – 6 85.7 – 2.874 0.165*

No

8 53.3 – 1 14.3 –

Nausea Yes

6

40

6

85.7

3.840

No

9

60

1

14.3

Yes

3

20

5

71.4

No

12

80

2

28.6

0.074*

Diarrhea 5.207

0.052*

Bottom right Abdominal pain Yes

11 73.3 – 1 14.3 – 6.407 0.020*

No

4 26.7 – 6 85.7 –

Generalized pain Yes

4 26.7 – 6 85.7 – 6.407 0.020*

No

11 73.3 – 1 14.3 –

Pain duration (day)

15

1.87

7

3.43

2.271

0.023¥

Leucocyte count (μL)

15

12040

7

17401

2.152

0.031¥

CRP (mg/dL)

15

4.76

7

14.68

2.153

0.031¥

Mann Whitney–U Test. *Fisher’s Exact Test. CRP: C-reactive protein.

¥

was not statistically significantly correlated with the Hinchey stages. In general, 59% of the patients had fever (>38.2°C), 54.5% had nausea, and 36.3% had diarrhea, but these were not statistically significantly correlated with the Hinchey stages. A total of 73.3% of the right lower abdominal pain in the RCD patients was seen in the Hinchey Stage I patients, and this was statistically significant (p<0.05). On the other hand, 85.7% of the generalized abdominal pain was seen in the Hinchey Stage II patients, and this was statistically significant (p<0.05). Duration of pain was higher in the Hinchey Stage II patients (average 3.43 days), and this was statistically significant (p<0.05). Leukocyte and CRP levels were statistically significant in the Hinchey Stage II patients (mean leukocytes, 17,401 μL; CRP 14.68 mg/dL) (p<0.05) (Table 1).

verticulitis. Right hemicolectomy and primary anastomosis were performed. This patient was discharged with healing after 8 days with no mortality and morbidity in the postoperative period.

Appendectomy was performed in 2 patients (9%) as a treatment. Preoperative radiological examinations of these patients were diagnosed as acute appendicitis. One of them was the Hinchey Stage I, and the other was Stage II cecum diverticulitis during the operation. Another patient (4.5%) had a complex abscess with the Hinchey Stage II cecum di-

A percutaneous drainage catheter was placed under sonography in 4 patients (18.1%) in who the localized abscess did not regress with conservative treatment. Percutaneous abscess drainage was applied in 2 Hinchey Stage I patients and 2 Hinchey Stage II patients. Patients with a drainage catheter were discharged after 4–5 days of treatment, followed by oral

398

Symptomatic conservative treatment was applied in other 19 patients (86.3%). Conservative treatment was applied in 14 Hinchey Stage I RCD patients and 5 Hinchey Stage II RCD patients. Oral intake in these patients was discontinued for 2–3 days, intravenous hydration therapy with balanced solutions was given, intravenous dual antibiotherapy was applied, including antibiotics such as third-generation cephalosporins and metronidazole, and after 2–8 days (mean, 3.7 days), they were discharged by oral antibiotics.

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Destek et al. Effectiveness of conservative approach in right colon diverticulitis

Table 2. Treatment and recurrence status of patients with right colon diverticulitis Parameters

Hinchey Hinchey Stage I Stage II

Results

n % n % Value p

Treatment Conservative 14 93.3 5 71.4 1.856 0.227* Surgery

1 6.7 2 28.6

Percutaneous drainage Yes

2 13.3 2 28.6 0.711 0.565*

No

13 86.7 5 74.1

Recurrences Yes

2 13.3 2 28.6 0.711 0.565*

No

13 86.7 5 74.1

Distribution of localizations (n)

antibiotics. After treatment of all patients, appropriate physical activity, probiotics, and high-fiber diet of herbal origin were recommended to all patients, and they were followed up (Table 2). 12 10

10 8 6

5

4

4

3

2 0

Cecum

I

Right colon

Cecum

Hinchey Stage

II

Right colon

Figure 2. Hinchey Stages of right colon diverticulitis and distribution of localization.

Treatment and status recurrence (n)

16

Treatment Recurrence

14

14

DISCUSSION The pathophysiology of CDD is very complex and is related to colonic motility disorders, chronic inflammation in the colon wall, and microflora imbalance.[1,2,6] In the etiology, factors such as genetics, lineage, reduced fiber intake, obesity, lack of physical activity, muscle diseases, etc. were found to be related to CDD.[6,7] CCD has two forms. Congenital diverticulum is a true diverticulum containing all layers of the column. Acquired diverticulum is a false diverticulum consisting of only colon mucosa.[1–3] Right colon diverticula are usually solitary and true diverticula; muscle hypertrophy is not observed.[7,8] In Western societies, 95% of CDD cases are found in the sigmoid and left colon, 1%–2% in the right colon, and 6%–10% in the whole colon.[3,6] Approximately, 20% of the cases of CDD occur in the Eastern societies, 70% of which are in the right colon, and 10%–15% are in the left colon.[6–8] This difference is thought to be due to environmental factors, life diversity, and genetics.[2,7,8] The most important CDD complication is acute colonic diverticulitis, observed in 10%–25% of the cases.[1,2] The pathogenesis of diverticulitis occurs in the form of pressure increase, inflammation, focal necrosis, and micro and macro perforation in diverticula.[2,6] In 25% of the cases, complicated diverticulitis may occur, and intra-abdominal abscess, perforation, fistula, or obstruction may develop. The mortality rate may range between 12%–36%.[1,3,6] 41% of CCD cases requiring emergency hospitalization are colon diverticulitis, and 20% of them are operated.[9] Strategies for treatment and follow-up have been developed by staging colon diverticulitis.[10,11] The most commonly used of them is the Hinchey staging, which was developed in 1978 and then modified.[6,11] Currently, new staging methods are continued to be developed.[12] We used the Hinchey staging in the present study.

12 10 8 6

After 2 years of follow-up, no recurrence was detected in patients undergoing surgery. Two Hinchey Stage I patients with conservative treatment and 2 Hinchey Stage II patients developed recurrence. The recurrence status according to the Hinchey stages was not statistically significant. Since recurrence attacks were not complicated, the patients were treated conservatively again, followed by a high-fiber dietary recommendation (Fig. 3).

5

4 2 0

1

2 0

Surgery

2

2 0

Conservtive

Surgery

Conservtive I II Distribution according to Hinchey Stage

Figure 3. Prognosis status of patients with right colon diverticulitis.

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In our research, patients with right-sided diverticulitis constituted 14.4% of CDD. This was an expected rate for our country, which is located between the Eastern and Western worlds. In our study, 68.1% of the patients were evaluated as the Hinchey Stage I, and 31.8% of them as the Hinchey Stage II diverticulitis. 399


Destek et al. Effectiveness of conservative approach in right colon diverticulitis

In a study, the mean age of patients with RCD was 41.9, and 78.4% of them were male. Patients with RCD usually had localized peritonitis.[13] The morbidity rate was 14.2%, and the mortality rate was zero.[13] In the present study, the female-to-male ratio of the patients with RCD was 0.69, and the mean age was 50.9 years. The mean age of the Hinchey Stage II patients was 63.57 years, and this was statistically significant. Especially the RCD located in the cecum mostly mimics acute appendicitis.[4,5,13] Studies have shown that RCD was found in 2.7% of the patients who underwent laparotomy with a diagnosis of acute appendicitis.[14] In laparotomies for appendectomy, the main pathology was RCD in 1 out of 300 appendicitis cases.[15] Research suggests that appendectomy should be performed to accurately follow-up diverticulitis in such a case.[5,11] In the present study, there were 2 patients undergoing appendectomy for acute appendicitis, but they were diagnosed with cecal diverticulitis. Pain occurring in 93%–100% of the patients with RCD begins directly in the lower-right quadrant and lasts a long time; in advanced cases, pain becomes generalized.[13] To a lesser extent, there are also nausea and vomiting.[15,16] In the present study, right lower abdominal pain was found in 73.3% of the Hinchey Stage I patients, and this was statistically significant. The generalized abdominal pain was seen in 85.7% of the Hinchey Stage II patients, and this was statistically significant. Pain duration was longer in the Hinchey Stage II patients (average, 3.43 days), and this was statistically significant. Leukocytosis is found in 58% of the patients with RCD.[4,5] Studies have shown that the leukocyte count and fever are not valuable in distinguishing complicated and non-complicated diverticulitis.[17] On the other hand, it has been reported that CRP can be used as an indicator for the presence of complications. In addition, CRP is a useful tool in predicting the clinical severity of acute diverticulitis.[17,18] However, the presence of a low CRP complex does not mean that the disease can be excluded safely.[17,18] In the present study, the leukocyte and CRP levels were higher in the Hinchey Stage II patients and were statistically significant. A radiologic examination is the primary diagnostic method for colon diverticulitis.[11,17] Radiologically, water-soluble contrast-enema radiography, abdominal sonography, contrast-enhanced tomography, and magnetic resonance imaging (MRI) are used.[5,6] In the studies, sonography had the sensitivity of 77%–98% and specificity of 80%–99%; MRI had the sensitivity of 86%–94% and specificity of 88%–92%.[20] Although sonography and MRI detect some complications of acute diverticulitis and occasionally show differential diagnoses, they are not as sensitive as contrast-enhanced tomography for these indications.[4,10,19] Contrast-enhanced tomography has the sensitivity and specificity of 99% in right-sided 400

diverticulitis.[5,11,19] In the present study, all patients underwent abdominal sonography and contrast-enhanced abdominal CT. The Hinchey Stage I patients with uncomplicated diverticulitis and isolated paracolic abscesses <5 cm in size on a radiological evaluation without clinical peritonitis findings can be treated conservatively with antibiotics and intestinal resting. [5,21–23] If the patient’s clinical condition does not improve, the colon resection and primary anastomosis can be planned.[24,25] If RCD is solitary, only diverticulectomy can be performed because it causes less complication.[3,5] The Hinchey Stage II patients have a pericolic, pelvic, and retroperitoneal limited abscess, but if the abscess is <5 cm, and the patient’s general condition is good, they may recover with conservative medical treatment.[9,21] Otherwise, colon resection is performed with primary anastomosis.[9,21] In 14% of patients with complicated Hinchey Stage II colon diverticulitis, coloileal, colovaginal, and colorectal fistulas may be found, and additional surgical procedures may be required. [11,20] Laparoscopic surgery can be performed safely and effectively in the Hinchey Stage I and II RCD patients.[22,23] The Hinchey Grade III colon diverticulitis is associated with purulent peritonitis, has a mortality rate of 15%–35%, and a morbidity rate of 70%–80%. Segmental colectomy with laparotomy is recommended as emergency surgery in these patients.[11,20,26] Modified Hinchey Stage IV colonic diverticulitis has fecal peritonitis, and its mortality rate is 6 times higher than of purulent peritonitis.[9,27] These patients should have an emergent open laparotomy, peritoneal lavage, segmental colectomy, and stoma.[11,26,27] Percutaneous drainage appears to be an optimal first-line treatment of Stage I and II colonic diverticulitis with an abscess diameter ≥5 cm.[11] This option results in a lower morbidity and mortality compared to emergency surgery and up to 74% success rates.[11,24] Percutaneous drainage allows for stabilization of the patient, stage regression, and the performance of definitive surgical procedures under elective conditions.[9,24] Colonoscopy control is recommended to exclude the neoplasm at least 6 weeks after an acute diverticulitis attack.[3,11] In other studies, 10-year recurrence rates after conservative treatment of non-complicated RCD patients, which make 75% of RCD cases, is approximately 20%–30%.[22,23] In complicated patients, which account for 25% of RCD cases, a recurrence rate in the 10-year follow-up after surgical treatment is 2%–10%.[6,9,22] In the present study, 19 (86.3%) patients were treated conservatively, and 4 (18.1%) patients underwent percutaneous drainage catheterization. Of the 19 patients treated conservatively, only 4 patients (21%) developed RCD and were treated symptomatically. Ulus Travma Acil Cerrahi Derg, July 2019, Vol. 25, No. 4


Destek et al. Effectiveness of conservative approach in right colon diverticulitis

Conclusion Conservative treatment methods should be preferred, especially if there is non-complicated RCD. Surgical treatment should generally be used in patients unresponsive to conservative treatment, and in the treatment of complicated and recurrent cases. The authors declare that they have no conflicts of interest. All authors have read and approved the final version of the manuscript. Conflict of interest: None declared.

REFERENCES 1. Young-Fadok TM, Roberts PL, Spencer MP, Wolff BG. Colonic diverticular disease. Curr Probl Surg 2000;37:457−514. 2. Tursi A, Papa A, Danese S. Review article: the pathophysiology and medical management of diverticulosis and diverticular disease of the colon. Aliment Pharmacol Ther 2015;42:664−84. 3. Choi CS, Cho EY, Kweon JH, Lim PS, No HJ, Kim KH, et al. The prevalence and clinical features of colonic diverticulosis diagnosed with colonscopy. Korean J Gastrointest Endosc 2007;35:146–51. 4. Radhi JM, Ramsay JA, Boutross-Tadross O. Diverticular disease of the right colon. BMC Res Notes 2011;4:383. 5. Stollman N, Raskin JB. Diverticular disease of the colon. Lancet 2004;363:631−9. 6. Hinchey EJ, Schaal PG, Richards GK. Treatment of perforated diverticular disease of the colon. Adv Surg 1978;12:85−109. 7. Commane DM, Arasaradnam RP, Mills S, Mathers JC, Bradburn M. Diet, ageing and genetic factors in the pathogenesis of diverticular disease. World J Gastroenterol 2009;15:2479−88. 8. Telem DA, Buch KE, Nguyen SQ, Chin EH, Weber KJ, Divino CM. Current recommendations on diagnosis and management of right-sided diverticulitis. Gastroenterol Res Pract 2009;2009:359485. 9. Schwesinger WH, Page CP, Gaskill HV 3rd, Steward RM, Chopra S, Strodel WE, et al. Operative management of diverticular emergencies: strategies and outcomes. Arch Surg 2000;135:558−62. 10. Klarenbeek BR, de Korte N, van der Peet DL, Cuesta MA. Review of current classifications for diverticular disease and a translation into clinical practice. Int J Colorectal Dis 2012;27:207−14. 11. Barat M, Dohan A, Pautrat K, Boudiaf M, Dautry R, Guerrache Y, et al. Acute colonic diverticulitis: an update on clinical classification and management with MDCT correlation. Abdom Radiol (NY) 2016;41:1842−50. 12. Lee IK, Jung SE, Gorden DL, Lee YS, Jung DY, Oh ST, et al. The diagnostic criteria for right colonic diverticulitis: prospective evaluation of

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100 patients. Int J Colorectal Dis 2008;23:1151−7. 13. Law WL, Lo CY, Chu KW. Emergency surgery for colonic diverticulitis: differences between right-sided and left-sided lesions. Int J Colorectal Dis 2001;16:280−4. 14. Park CW, Kim BG, Kim KS, Byun YH, Cho KH, Byun SH, et al. Surgical management of caecal diverticulitis detected during appendectomy. J Korean Soc Coloproctol 2001; 17:15−9. 15. Violi V, Roncoroni L, Boselli AS, Trivelli M, Peracchia A. Diverticulitis of the caecum and ascending colon: an unavoidable diagnostic pitfall? Int Surg 2000;85:39−47. 16. Kalcan S, Başak F, Hasbahçeci M, Kılıç A, Canbak T, Kudaş İ, et al. Intraoperative diagnosis of cecal diverticulitis during surgery for acute appendicitis: Case series. Ulus Cerrahi Derg 2015;32:54−7. 17. van de Wall BJ, Draaisma WA, van der Kaaij RT, Consten EC, Wiezer MJ, Broeders IA. The value of inflammation markers and body temperature in acute diverticulitis. Colorectal Dis 2013;15:621−6. 18. Kechagias A, Rautio T, Kechagias G, Mäkelä J. The role of C-reactive protein in the prediction of the clinical severity of acute diverticulitis. Am Surg 2014;80:391−5. 19. Kang JY, Melville D, Maxwell JD. Epidemiology and management of diverticular disease of the colon. Drugs Aging 2004;21:211−28. 20. DeStigter KK, Keating DP. Imaging Update: Acute Colonic Diverticulitis. Clin Colon Rectal Surg 2009;22:147−55. 21. Yardımcı E, Hasbahçeci M, İdiz UO, Atay M, Akbulut H. Is surgery necessary to confirm diagnosis of right-sided diverticulitis in spite of relevant clinical and radiological findings? Ulus Travma Acil Cerrahi Derg 2017;23:61−5. 22. Komuta K, Yamanaka S, Okada K, Kamohara Y, Ueda T, Makimoto N, et al. Toward therapeutic guidelines for patients with acute right colonic diverticulitis. Am J Surg 2004;187:233−7. 23. Yang HR, Huang HH, Wang YC, Hsieh CH, Chung PK, Jeng LB, et al. Management of right colon diverticulitis: a 10-year experience. World J Surg 2006;30:1929−34. 24. Gregersen R, Mortensen LQ, Burcharth J, Pommergaard HC, Rosenberg J, et al. Treatment of patients with acute colonic diverticulitis complicated by abscess formation: A systematic review. Int J Surg 2016;35:201−8. 25. Stabile BE, Puccio E, vanSonnenberg E, Neff CC. Preoperative percutaneous drainage of diverticular abscesses. Am J Surg 1990;159:99−104. 26. Schultz JK, Yaqub S, Wallon C, Blecic L, Forsmo HM, Folkesson J, et al. Laparoscopic Lavage vs Primary Resection for Acute Perforated Diverticulitis: The SCANDIV Randomized Clinical Trial. JAMA 2015;314:1364−75. 27. Cirocchi R, Trastulli S, Desiderio J, Listorti C, Boselli C, Parisi A, et al. Treatment of Hinchey stage III-IV diverticulitis: a systematic review and meta-analysis. Int J Colorectal Dis 2013;28:447−57.

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ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Sağ kolon divertikülitinde konservatif yaklaşımın etkinliği Dr. Sabahattin Destek,1 Dr. Vahit Onur Gül2 1 2

Bezmiâlem Vakıf Universitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İstanbul Gülhane Eğitim Araştırma Hastanesi, Genel Cerrahi Kliniği, Ankara

AMAÇ: Kolon divertikül hastalarının yaklaşık %10–25’i hayatları boyunca kolon divertiküliti ile karşılaşmaktadırlar. Batı ülkelerinde sağ taraflı divertiküler hastalık nadir görülen bir durum iken, Asya ülkeleri arasında yaygındır. Bu çalışmanın amacı, sağ kolon divertiküliti saptanılan hastalarımızın klinik ve tedavi sonuçlarını değerlendirmektir. GEREÇ VE YÖNTEM: 2011 ve 2015 yılları arasında çekum ve sağ kolon divertiküliti tanısıyla tedavi edilen 22 hastanın demografik ve klinik verileri analiz edildi. Radyolojik inceleme ve klinik bulgulara göre hastalara Hinchey Evrelemesi yapıldı. Daha sonra Hinchey Evrelemesine göre hastaların demografik ve klinik özelliklerinin oransal olarak değerlerine ve istatistiksel olarak olarak anlamlılığına bakıldı. BULGULAR: Araştırmamıza sağ kolon divertiküliti tanısı konulan 22 hasta alındı. Kadın/erkek oranı 0.69 idi. Karın tomografisi ile yapılan değerlendirme sonrasında hastaların %68.1’i Hinckey evre I, %31.8’i Hinckey evre II divertikülit saptandı. Çoğunlukla Hinchey Evre I divertikülit sağ kolonda (%66.7) ve Hinchey Evre II divertikülit çekumda (%57.1) bulundu. Hinchey Evre II hastalarının ortalama yaşı daha yüksekti (ortalama, 63.6 yıl) ve istatistiksel olarak anlamlıydı (p<0.05). İki hastada apendektomi ve bir hastada sağ hemikolektomi yapılmıştı. Diğer 19 hastaya konservatif tedavi uygulandı. Ortalama hastanede yatış süresi 3.4 gündü. İki yıllık takipte konservatif tedavi alan dört hastada nüks görüldü; cerrahi tedavi alan hastalarda nüks görülmedi. TARTIŞMA: Sağ kolon divertiküliti genellikle doğu toplumlarında 50 yaş altı erkeklerde ve soliter olarak görülmektedir. Tedavi seçeneği olarak özellikle komplike olmayan olgularda konservatif yöntemler tercih edilmelidir. Cerrahi tedavi ise genellikle nüks ve komplike olguların tedavisinde kullanılmalıdır. Anahtar sözcükler: Hinchey Evrelemesi; konservatif tedavi; sağ kolon divertiküliti. Ulus Travma Acil Cerrahi Derg 2019;25(4):396-402

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doi: 10.14744/tjtes.2019.47382

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ORIG I N A L A R T IC L E

Effects of psychological factors on the clinical outcomes of fifth metacarpal neck fractures and their relation to injury etiology Levent Adıyeke, M.D.,1 Suavi Aydoğmuş, M.D.,2 Emre Bilgin, M.D.,4 Tahir Mutlu Duymuş, M.D.5 1

Mustafa Sabuncuoğlu, M.D.,3

Department of Orthopedic Surgery, Haydarpaşa Numune Training and Research Hospital, İstanbul-Turkey

2

Department of Orthopedic Surgery, Maltepe State Hospital, İstanbul-Turkey

3

Department of Psychiatry, Ümraniye Training and Research Hospital, İstanbul-Turkey

4

Department of Orthopedic Surgery, İzmir Tepecik Training and Research Hospital, İzmir-Turkey

5

Department of Orthopedic Surgery, Saygı Hospital, İstanbul-Turkey

ABSTRACT BACKGROUND: The fifth metacarpal neck fracture injuries are commonly found in patients who applied to emergency clinics. The mechanism of trauma in these types of injuries seems to be different and, in some cases, appears to be intentional. Psychological factors play an important role in the treatment and rehabilitation, as well as in the etiology of metacarpal neck fractures. However, to the best of our knowledge, no research has yet compared the clinical outcomes of patients with fifth metacarpal neck fractures caused intentionally with those of patients with such fractures caused by unintentional injuries. Our goal is to investigate the relationships between the mechanism of injury, socioeconomic status, and clinical outcomes of patients with fifth metacarpal neck fractures. METHODS: The study included 59 patients with fifth metacarpal neck fractures. The patients were separated into two groups. Group 1 consisted of patients with intentional injuries, and Group 2 consisted of patients with unintentional injuries. Both groups were evaluated in terms of the anger analysis, impulsivity, and the level of anxiety in relation to somatic findings Visual Analogue Scale (VAS) and The Disabilities of the Arm, Shoulder and Hand Score (QDASH). In addition, the relationship between anger, impulsivity, and anxiety scores with the socioeconomic status and educational level was assessed. RESULTS: It was observed that the anger and impulsivity values of Group 2 patients were lower than the Group 1, and the decrease in Group 2 was correlated with the VAS and Q-DASH values. Group 1 barrat impulsivity score 61.5 (42–78), anxiety score 64 (55–77), state anger score 20 (16–30), and Group 2 barrat impulsivity score 61 (55–69), anxiety score 66 (58–72), and anger score 19 (14–26) were found as mean values. The impulsivity score and anger score were found to be lower in Group 2 at the low educational level. The number of patients with a low income was found to be high in both groups, and the impulsivity score and the anger score were higher in Group 1, while the anxiety score was higher in Group 2. CONCLUSION: Sociodemographic factors and the etiology of intentional injuries could not be detected, but psychological factors play a role in the clinical sequelae of intentional fifth metacarpal fractures, their effects thereof on the hand function and the pain course after treatment. Keywords: Etiology; emergency; fifth metacarpal; intentional injuries; pain.

INTRODUCTION Hand injuries are the common cause of emergency room

or outpatient clinics visits. Upper-extremity fractures constitute 30%–40% of all fractures, and 10% of hand fractures are metacarpal or phalangeal fractures, most commonly the

Cite this article as: Adıyeke L, Aydoğmuş S, Sabuncuoğlu M, Bilgin E, Duymuş TM. Effects of psychological factors on the clinical outcomes of fifth metacarpal neck fractures and their relation to injury etiology. Ulus Travma Acil Cerrahi Derg 2019;25:403-409. Address for correspondence: Levent Adıyeke, M.D. Haydarpaşa Numune Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, İstanbul, Turkey Tel: +90 216 - 542 32 32 E-mail: leventadiyeke@gmail.com Ulus Travma Acil Cerrahi Derg 2019;25(4):403-409 DOI: 10.5505/tjtes.2018.93928 Submitted: 17.09.2018 Accepted: 24.11.2018 Online: 13.12.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Adıyeke et al. Effects of psychological factors on the clinical outcomes of fifth metacarpal neck fractures and their relation to injury etiology

fifth metacarpal neck fractures.[1–3] Such fractures are caused by direct or indirect trauma. The common mechanisms of injury are falls, house accidents, and work accidents, but approximately 13% develop after punching hard surfaces. [4,5] Self-inflicted injuries are often observed in patients who abuse alcohol or drugs and who suffer from major depression or psychotic or personality disorders.[6] The trauma causing hand injury may have been intentional in the sense that the patient wished to harm himself or herself or exhibited aggression toward another person. Some variables in hand-injured individuals have a somatic effect on the clinical process and outcomes. Although hand injuries are not life-threatening, they compromise daily activities and cause prolonged lost work days.[5,7,8] Psychological factors play an important role in the treatment and rehabilitation, as well as in the etiology of injury. Several studies have shown that severe anxiety, catastrophic thinking, pain, and exaggerated reactions are associated with persistent pain and disability after treatment. In this respect, it is suggested that intentional injuries treatment results may change depending on these factors.[9–13] However, to the best of our knowledge, no research has yet compared the clinical outcomes of patients with the fifth metacarpal neck fractures caused intentionally with those of patients with such fractures caused unintentionally.

Purpose of the Study The aim of this study is to investigate the relationships between the mechanism of injury, socioeconomic status, and clinical outcomes of patients with the fifth metacarpal neck fractures.

MATERIALS AND METHODS We examined a total 107 patients with the fifth metacarpal neck fractures, who were treated between January 2014 and January 2016. All patients were treated via closed reduction and cast splinting. Patients with intra-articular fractures, comminuted fractures, open fractures, and/or tendon injuries and those who missed outpatient appointments and/or did not comply with treatment instructions were excluded. Finally, 59 patients with intentional or unintentional fifth metacarpal neck fractures were included in the study. All patients gave their written informed consent for study participation. The study was approved by the local ethic committee. The patients were separated into two groups. Group 1 consisted of patients with intentional injuries, and Group 2 consisted of patients with unintentional injuries.

ated. The final clinical outcomes were assessed using a visual analog scale (VAS) for pain and the work and sports/performing arts modules of the Disabilities of the Arm, Shoulder, and Hand (Q-DASH) questionnaire. Patients were seen in the outpatient clinic or contacted by telephone (Fig. 1).

Psychological Evaluation Scales The SSTAS, which is appropriate for both adolescents and adults, is a 34-item self-report measure that evaluates state anger (SSTAS-SA), trait anger (SSTAS-TA), anger inside (SSTAS-AI), anger outside (SSTAS-AO), and anger control (SSTAS-AC) using various subscales. The 10 primary questions evaluate trait anger, and the remaining 24 address the characteristics of anger (anger inside, anger outside, and anger control). High scores on the trait anger subscale reflect greater anger; high scores on the anger control subscale reflect more anger control; high scores on the anger-outside subscale reflect that anger tends to be directed outward; and high scores on the anger-inside subscale reflect that anger tends to be directed inward. The STAI features two different scales, one measuring state anxiety (Form 1) and the other measuring trait anxiety (Form 2); each includes 20 items. In this study, we used the Turkish translations of the original X forms of the STAI (STAI TX-1 and 2). The state anxiety scale explores how an individual feels at certain times and in specific situations, whereas the trait anxiety scale determines how that person feels in the absence of any particular situation or set of circumstances. All study participants completed the STAI TX-1 questionnaire to assess state anxiety and the STAI TX-2 questionnaire to assess trait anxiety. The responsible researcher marked the statements that best corresponded to the answers given by the participants in terms of the level of anxiety. After the questionnaire was administered, the scores were manually added up to calculate individual STAI scores. The validity and reliability of the Turkish form of the STAI were confirmed by Oner and Le Compte.[17] The BIS-11, which is a widely used measure of impulsiveness, includes 30 items addressing six first-order factors (attention, motor behavior self-control, cognitive complexity, perseverance, and cognitive instability/impulsiveness) and three second-order factors (attentional, motor, and non-planning impulsiveness). Psychological Evaluations

404

Clinical Outcomes Visual Analog Scale

Anger Scale (SSTAS)

Age

(VAS)

State–Trait Anxiety

Sex

Scale (STAI) Barratt Impulsiveness

Psychological evaluations were performed by physicians using the Spielberg State–Trait Anger Scale (SSTAS), the State–Trait Anxiety Scale (STAI), and the Barratt Impulsiveness Scale (BIS-11).[14–16] Sociodemographic variables were also evalu-

Sociodemographic Variables

Spielberg State–Trait

Scale (BIS-11)

Occupation Marital Status Level Of Income

Disabilities of the Arm, Shoulder, and Hand (Q-DASH)

Education Status Alcohol Or Drug Use

Figure 1. Patients evaluation diagram with psychological and sociodemographic variables and clinical outcome schemes.

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Adıyeke et al. Effects of psychological factors on the clinical outcomes of fifth metacarpal neck fractures and their relation to injury etiology

SOCIO-DEMOGRAPHIC QUESTIONNAIRE AGE: SEX: OCCUPATION: MARITAL STATUS: MARRIED

SINGLE

EDUCATION LEVEL: LOW EDUCATIONAL LEVEL (LESS THEN

MIDDLE SCHOOL)

HIGH EDUCATION LEVEL (LESS THEN

UNIVERSITY)

UNIVERSITY AND POSTGRADUATE LEVEL

LEVEL OF INCOME: LOW (LOWER OR MINIMUM WAGE)

MEDIUM (MONTHLY INCOME IS BETWEEN

TWO AND FIVE TIMES RATHER WAGE)

HIGH (MONTHLY INCOME IS OVER FIVE

TIMES RATHER WAGE)

MECHANISM OF INJURY (HOW DID IT HAPPEN?)

continuous and non-normally distributed parameters were analyzed by calculating Spearman’s rho correlation coefficients. Statistical significance was associated with a two-sided p-value <0.05.

RESULTS We enrolled 51 (86.4%) males and 8 (13.6%) females with a mean age of 26.6±9.6 (14–57) years; the mean follow-up time was 18±5 months. The demographic characteristics of the sample are presented in Table 1. The first group included 28 (47.5%) patients, and the second group included 31 (52.5%) patients. Fifty-six (94.9%) patients had experienced first fractures. No patient had any history of a psychiatric disorder, and no patient believed that he or she needed psychiatric assistance.

CAUSE OF TRAUMA (WHY DID YOU HIT?) DID YOU USE ANY DRUGS OR TAKE ALCOHOL BEFORE INJURY? IS THIS THE FIRST TIME YOU BROKE YOUR BONE? HAVE YOU EVER TAKEN ANY PSYCHIATRIC TREATMENT BEFORE? DO YOU THINK THAT YOU NEED A PSYCHIATRIC TREATMENT?

Figure 2. Sociodemographic information scheme.

Clinical Evaluation Somatic Data Scores Sociodemographic information on all patients was collected using a sociodemographic evaluation scheme (Fig. 2). Final clinical evaluations were performed in terms of the visual analogue scale (VAS) and quick arm–shoulder–hand disability questionnaire (Q-DASH) scores. Pain severity was assessed with a VAS. Patients rated the intensity of pain on a form “no pain” to “maximal, worst pain imaginable.” The VAS score is the pain level as indicated by the patient.

Both groups were evaluated in terms of the anger analysis, impulsivity, and the level of anxiety in relation to somatic VAS and QDASH findings. It was seen that the anger and impulsivity values of Group 2 patients were lower than the Group 1, and the decrease in Group 2 was correlated with the VAS and Q-DASH values. An anxiety score was higher in Group 2 (Table 2). Both groups anger subscores were evaluated in terms of the VAS and QDASH score correlation. Group 2 anger state pvalue < 0.05 negative correlation -score decrase -between the SSTAS-AO and VAS scores was found. There was no correlation between the anger state subscores and Q-DASH scores in both groups (Table 3) (Spearman’s correlation p=0.026). Table 1. Demographic characteristics of the samples

The Q-DASH is a questionnaire that measures physical function and symptoms in patients with upper extremity problems, and Turkish validity and reliability were confirmed.[18–20]

Group 1

n % n %

Statistical Analysis

Gender

Statistical analyses were performed using the MedCalc Statistical Software version 12.7.7 (MedCalc Software bvba, Ostend, Belgium; http://www.medcalc.org; 2013). The normality of continuous variables was determined using the Shapiro– Wilk test. Descriptive statistics are presented as the means and standard deviations for normally distributed variables and as medians (with minimum–maximum) for non-normally distributed variables. Student’s t-test was used to compare normally distributed parameters. Non-parametric statistical methods were used to compare values with skewed distributions. The Mann–Whitney U test was employed to compare non-normally distributed values. To compare several non-normally distributed values, the Kruskal–Wallis test was employed. The correlations between continuous and normally distributed parameters were determined by calculating Pearson correlation coefficients. The correlations between

Male

27 45 24 40

Female

1 1.6 7 11

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Group 2

Marital status

Single, divorced or widowed

Married

19

32

15

25

9 15 16 27

Educational status

Nil or primary

10

16

6

10

Secondary

13 22 20 33

5

8.4

5

8.4

7

11

8

13

University and postgraduate level

Level of Income

Low (min. wage)

Middle*

21 35 22 37

High**

0 0 1 1.6

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Adıyeke et al. Effects of psychological factors on the clinical outcomes of fifth metacarpal neck fractures and their relation to injury etiology

Table 2. Associations of anger analysis, impulsivity and level of anxiety in relation to VAS and QDASH scores

Table 3. Association of anger subscores with VAS and Q-DASH scores

r; p

STAI TX-1 STAI TX-2 Average Anxiety Score Barratt Impulsiveness Score SSTAS-Trait Anger SSTAS-State Anger

Group 1

Group 2

Mean±SD Mean±SD Median (min–max) Median (min–max)

(SSTAS-SA)

-0.185; 0.347

(SSTAS-TA)

-0.136; 0.491

-0.254; 0.193

(SSTAS-AI)

-0.125; 0.526

-0.198; 0.313

68.4±6.2

70.3±2.9 70 (64–76)

(SSTAS-AO)

-0.242; 0.215

-0.301; 0.119

58.7±7.9

61.8±3.6

(SSTAS-AC)

0.020; 0.919

0.079; 0.690

59 (39–74)

62 (56–70)

Group 2

(SSTAS-SA)

0.000; 0.998

-0.182; 0.328

(SSTAS-TA)

-0.399; 0.026

-0.319; 0.081

63.7±5.6

65.7±3.1

64 (55–77)

66 (58–72)

(SSTAS-AI)

-0.042; 0.821

-0.136; 0.466

61.8±8.8

61.6±3.8

(SSTAS-AO)

-0.010; 0.959

-0.153; 0.410

61.5 (42–78)

61 (55–69)

(SSTAS-AC)

-0.441; 0.013

-0.213; 0.250

20.3±7.0

19.4±3.9

18 (10–40)

20 (10–26)

20.8±3.6

19.2±2.6

20 (16–30)

19 (14–26)

13.7±2.9

14.1±2.4

14 (8–19)

14 (10–18)

SSTAS-Anger Outside

13.9±3.8

13.1±2.1

14 (9–23)

13 (9–16)

VAS: Visual Analog Scale; Q-DASH: Quick arm-shoulder-hand disability questionnaire; SSTAS: Spielberg State–Trait Anger Scale; SA: State anger; TA: Trait anger; AI: Anger inside; AO: Anger outside; AC: Anger control.

Table 4. Associations of Barratt Impulsiveness Scale scores with VAS and Q-DASH scores r; p

VAS

Q-DASH

21.6±5.6

19.2±4.1

Group 1 Barratt Impulsiveness

-0.163; 0.407 -0.083; 0.673

21.5 (12–32)

20 (12–32)

Group 2 Barratt Impulsiveness

-0.381; 0.034 -0.305; 0.095

VAS

4.7±1.4 2.7±1.0

5 (2–7)

3 (1–5)

Q-DASH

10.6±3.3 6.9±1.6

11 (5–18)

VAS: Visual Analog Scale; Q-DASH: Quick arm-shoulder-hand disability questionnaire.

7 (4–10)

VAS: Visual Analog Scale; Q-DASH: Quick arm-shoulder-hand disability questionnaire; SSTAS: Spielberg State–Trait Anger Scale; STAI: State–Trait Anxiety Scale; SD: Standard deviation.

Group 1 Barrat impulsivity score 61.5 (42–78) and Group 2 Barrat impulsivity score 61 (55–69) were found as the mean values. The medium level negative Spearman correlation of p=0.034 between the BIS-11 and VAS scores and the QDASH scores in Group 2 was found. No negative correlation was observed between the VAS and Q-DASH scores in Group 1 (Table 4). In Group 1, the mean anxiety score was 64 (55–77), and in Group 2, the mean anxiety score was 66 (58–72). There was a moderate statistical correlation between anxiety subscores and the VAS score in Group 2 (Spearman’s correlation, p=0.002). In Group 2, both anxiety subscores were found to be higher than in Group 1 and moderately significant correlations among the Q-DASH, state anxiety, and trait anxiety subscores (Pearson’s correlation p-value <0.05). Group 1 had higher VAS scores (Mann–Whitney U test, p<0.001; Table 5). The educational level was compared in both groups, and it 406

-0.185; 0.345

Group 1

69.5 (53–79)

Q-DASH

SSTAS-Anger Inside

SSTAS-Anger Control

VAS

Table 5. Associations of anxiety and VAS and Q-DASH scores r; p Group 1 STAI TX-1

VAS

Q-DASH

-0.135; 0.494 -0.131; 0.507

STAI TX-2

Average anxiety score -0.002; 0.992 -0.107; 0.589

0.009; 0.962 -0.064; 0.747

Group 2 STAI TX-1

-0.292; 0.111 -0.384; 0.033

STAI TX-2

-0.525; 0.002 -0.467; 0.008

Average anxiety score -0.347; 0.056 -0.329; 0.071

VAS: Visual Analog Scale; Q-DASH: Quick arm-shoulder-hand disability questionnaire. STAI: State–Trait Anxiety Scale.

was observed that in patients with the low educational level, impulsivity (Group 1, 64.1+5.6; Group 2, 60.5+3.5) and anger values (Group 1, 24+4.8; Group 2,18.8+5.3) were higher in Group 1 than in Group 2, although the anxiety value in patients with the university and postgraduate education level (Group 1, 58.6+1.7; Group 2, 66.2+3.5) was higher in Group 2. The University and postgraduate education level the STAI score was low in Group 1 (p<0.05). Ulus Travma Acil Cerrahi Derg, July 2019, Vol. 25, No. 4


Adıyeke et al. Effects of psychological factors on the clinical outcomes of fifth metacarpal neck fractures and their relation to injury etiology

Table 6. Distribution of education level over Anxiety, Impulsiveness and Angre score

High education level

Low education level

Univ. post–graduate level

Mean±SD Mean±SD Mean±SD Median (min–max) Median (min–max) Median (min–max)

Group 1

Average Anxiety Score

64.2±6.4; 64 (55–77)

Barratt Impulsiveness Score

60.8±10.8; 61 (42–78)

SSTAS–State Anger

18.8±7.9; 17 (10–40)

65.5±4.4; 67 (57–71)

p

58.6±1.7; 59 (56–60)

0.050

64.1±5.6; 63 (56–74)

60±9.1; 60 (49–70)

0.532

24±4.8; 24.5 (16–31)

16.8±6.4; 15 (10–27)

0.037

Group 2

Average Anxiety Score

66.3±2.7; 66 (63–72)

63.3±3.7; 63.5 (58–68)

66.2±3.5; 68 (61–68)

0.200

Barratt Impulsiveness Score

61.5±3.9; 61 (55–69)

60.5±3.5; 61.5 (55–64)

63.5±3.3; 62.5 (61–68)

0.473

SSTAS–State Anger

19.6±3.9; 20 (10–26)

18.8±5.3; 18 (12–26)

19.5±1.9; 19 (18–22)

0.846

SSTAS: Spielberg State–Trait Anger Scale;

Post-hoc comparisons revealed a significant difference between those whose formal education ended with high school and those who had attended university (Mann–Whitney U test; p<0.016 after Bonferroni correction). SSTAS scores according to the educational level in Group 1 had a significant difference (Kruskal–Wallis; p<0.05). Specifically, low education was associated with increased impulsivity scores and higher scores on all subscales of the SSTAS scale (Table 6).

Consistent with previous studies, patients in Group 1 were predominantly single males whose injuries were a result of punching glass. The most common context of this behavior was an argument or a fight, but no alcohol or drug abuse was observed in any patient. Fifty-five percent of patients diagnosed with fifth metacarpal neck fractures discontinued follow-up treatment after psychiatric evaluations were completed; the dropout rate was higher in Group 1.

Gender studies were not evaluated because the number of intentional patients was low in female patients.

Pain and deformity were the major complaints of patients during follow-up visits. Chronic pain is pain that persists even when the biophysiological pathology is totally or partially resolved.[12,22] Recent studies support the use of a biopsychological approach (thereby supporting patients psychologically), finding that patients with upper extremity injuries did not receive an adequate treatment.[23–25] Psychological factors were found to affect pain intensity and loss of the range of motion in those with chronic pain. Predisposing factors were depression, various emotional conditions, extreme pain anxiety, and exaggeration caused by negative pain perception, and disturbing thoughts concerning the illness.[26–28] Sönmez et al.[24] investigated 36 patients who developed hand injuries after punching glass and found that such patients were under greater psychological stress and had higher anger scores than the control group. Another study showed that patients with boxer’s fractures had higher anxiety levels, scored higher on anger subscales, and (mostly) exhibited maladaptive personality behaviors and anxiety symptoms; psychiatric evaluations should have been performed during the treatment of such patients.[29] We found a negative correlation between the VAS score (which measures chronic pain) and state anger and impulsiveness (which are related to intentional injuries) in Group 2. These were not related to the Q-DASH scores, which indicated that psychological factors affecting pain were less important. Pain was more significant in Group 1, but it was not associated with the range of motion loss.

The number of middle-income patients in both groups was high, and in these patients, impulsivity (Group 1, 66.4±5.8; Group 2, 61.6±3.8) and anger levels were also high (Group 1, 24.9±8.7; Group 2, 20.05±3.0) and anxiety levels (Group 1, 63.05±5.2; Group 2, 65.4±3.2) were found to be minimal among the groups (Fig. 3).

DISCUSSION The fifth metacarpal neck fracture is a common type of hand fracture, and it occurs primarily in young, active individuals. [2,21] Alcohol and drug abuse are very common in such patients.[4] In the present study, most patients were male, young, active workers, and middle school or high school graduates. Group 1 70 60

66

64

68

Low Middle

66

50 40 30

25

20

24

10 0

Avarage Anxiety Score

Barratt Impulsiveness Score

SSTAS-State Anger

Figure 3. Distribution of ıncome situation over the anxiety, ımpulsiveness, and anger scores.

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Several studies have shown that higher anxiety levels are associated with chronic pain and the range of motion loss.[30–33] 407


Adıyeke et al. Effects of psychological factors on the clinical outcomes of fifth metacarpal neck fractures and their relation to injury etiology

Ross et al.[30] found that psychological stress and depression affected pain, but anxiety state did not affect either pain or range of motion in the early period of healing (28 days). We suggest that biophysiological factors are primarily responsible for pain experienced in the first 28 days. Our analysis of the consistency of anxiety, as revealed by the VAS and Q-DASH, showed that that both trait anxiety and VAS scores were consistently (and negatively) significantly related to anxiety in Group 2. Also, we found statistically significant medium level negative correlations between the Q-DASH and the state and trait anxiety scores; thus, the level of anxiety affected both the pain and the range of motion. Although our patient numbers were reasonable, a larger sample size might have revealed more statistically significant differences. We had fewer patients with intentional than with unintentional injuries. Although we used a VAS and the QDASH to evaluate clinical outcomes, we did not compare the findings of physical examinations or the radiological results. Intentional injuries may reveal an outward expression of anger and impulsive reactions to stimuli. We found no evidence that such attitudes were related to the educational level. We found significant differences in trait anger and trait anxiety in Group 1 according to the educational level. However, we did not find that the educational level affected clinical outcome. A previous study found that patients with complex regional pain syndromes and those who underwent traumatic amputations were more likely than a control group to develop psychiatric disorders.[23,34] Psychiatric evaluation and support were suggested for such patients to improve their clinical outcomes and encourage them to accept treatment. We suggest that our study may guide future research along these lines.

Conclusion Psychological factors, such as anger, impulsiveness, and anxiety, play a role in the clinical sequelae of the intentional fifth metacarpal fractures, affecting thereof the hand function and the pain course after treatment. Conflict of interest: None declared.

REFERENCES 1. Henry MH, Bucholz RW, Heckman JD, Court BC. Fractures and dislocation of the hand. In: Bucholz RW, Heckman JD, Court BC, editors. Rockwood and Green’s Fractures in Adults. 6th ed. Philadelphia Lippincott Williams & Wilkins; 2005. p. 771–855. 2. Armangil M, Kayıpmaz M, Bilgin SS. Metacarpal fractures. TOTBİD Dergisi 2014;12:125–136. 3. Eldridge J, Apau D. Boxer’s fracture: management and outcomes. Emerg Nurse 2015;23:24–30. 4. Trybus M, Tusinski M, Guzik P. Alcohol-related hand injuries. Injury 2005;36:1237–40. 5. Trybus M, Lorkowski J, Brongel L, Hladki W. Causes and consequences of hand injuries. Am J Surg 2006;192:52–7.

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6. Çelik FG, Hocaoğlu Ç. Deliberate Self Harm B ehavior. Current Approaches in Psychiatry 2017;9:209–26. 7. Kadlub N, Danino A, Trost O, Robe N, Malka G. Boxer’s fracture: Cost evaluation orthopaedic or surgical treatment. [Article in French]. Chir Main 2006;25:152–5. 8. Vranceanu AM, Bachoura A, Weening A, Vrahas M, Smith RM, Ring D. Psychological factors predict disability and pain intensity after skeletal trauma. J Bone Joint Surg Am 2014;96:e20. 9. Bonzani PJ, Millender L, Keelan B, Mangieri MG. Factors prolonging disability in work-related cumulative trauma disorders. J Hand Surg Am 1997;22:30–4. 10. Galanakos SP, Bot AG, Zoubos AB, Soucacos PN. Psychological and social consequences after reconstruction of upper extremity trauma: methods of detection and management. J Reconstr Microsurg 2014;30:193– 206. 11. Özkan S, Zale EL, Ring D, Vranceanu AM. Associations Between Pain Catastrophizing and Cognitive Fusion in Relationto Pain and Upper Extremity Function Among Hand and Upper ExtremitySurgery Patients. Ann Behav Med 2017;51:547–54. 12. Booth J, Moseley GL, Schiltenwolf M, Cashin A, Davies M, Hübscher M. Exercise for chronic musculoskeletal pain: A biopsychosocial approach. Musculoskeletal Care 2017;15:413–21. 13. Ring D, Kadzielski J, Malhotra L, Lee SG, Jupiter JB. Psychological factors associated with idiopathic arm pain. J Bone Joint Surg Am 2005;87:374–80. 14. Özer AK. Sürekli öfke ve öfke ifade tarzı ölçekleri çalışması. Türk Psikoloji Dergisi 1994;31:26–35. 15. Öner N. Psychological Tests Used in Turkey: A Resource Reference. İstanbul: Bogazici University Press; 1996. 16. Spielberger CD, Gorsuch RL, Lushene R, Vagg PR, Jacobs GA. Manual for the State–Trait Anxiety Inventory. Consulting Psychologists Press Inc; Palo Alto, CA: 1983. 17. Güleç H, Tamam L, Yazıcı Güleç M, Turhan M, Karakuş G, Stanford MS. Psychometric properties of the Turkish version of the Barratt Impulsiveness Scale. 11. Bulletin of Clinical Psychopharmacology 2008;18:251–8. 18. McCormack HM, Horne DJ, Sheather S. Clinical applications of visual analogue scales: a critical review. Psychol Med 1988;18:1007–19. 19. Gummesson C, Ward MM, Atroshi I. The shortened disabilities of the arm, shoulder and hand questionnaire (QuickDASH): validity and reliability based on responses within the full-length DASH. BMC Musculoskelet Disord 2006;7:44. 20. URL:http://www.dash.iwh.on.ca/assets/images/pdfs/dashturkish.pdf 21. Pogliacomi F, Mijno E, Pedrazzini A, Tocco S, Tonani M, Ceccarelli F, et al. Fifth metacarpal neck fractures: fixation with antegrade locked flexible intramedullary nailing. Acta Biomed 2017;88:57–64. 22. Junghaenel DU, Schneider S, Broderick JE. Linguistic Indicators of Pain Catastrophizing in Patients With Chronic Musculoskeletal Pain. J Pain 2017;18:597–604. 23. Vranceanu AM, Barsky A, Ring D. Psychosocial aspects of disabling musculoskeletal pain. J Bone Joint Surg Am 2009;91:2014–8. 24. Sönmez A, Kora K, Öztürk N, Ersoy B, Aydin M, Numanoğlu A. Injury patterns and psychological traits of patients with self-inflicted wounds produced by punching glass. J Trauma 2010;69:691–3. 25. Mercan S, Uzun M, Ertugrul A, Ozturk I, Demir B, Sulun T. Psychopathology and personality features in orthopedic patients with boxer’s fractures. Gen Hosp Psychiatry 2005;27:13–7. 26. Nota SP, Bot AG, Ring D, Kloen P. Disability and depression after orthopaedic trauma. Injury 2015;46:207–12.

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Adıyeke et al. Effects of psychological factors on the clinical outcomes of fifth metacarpal neck fractures and their relation to injury etiology 27. Archer KR, Abraham CM, Obremskey WT. Psychosocial Factors Predict Pain and Physical Health After Lower Extremity Trauma. Clin Orthop Relat Res 2015;473:3519–26. 28. Ladds E, Redgrave N, Hotton M, Lamyman M. Systematic review: Predicting adverse psychological outcomes after handtrauma. J Hand Ther 2017;30:407–19. 29. Mayland EC, Hay-Smith EJ, Treharne GJ. Recovery-related anxiety and disability following upper limb injury: the importance of context. Disabil Rehabil 2015;37:1753–9. 30. Ross C, Juraskova I, Lee H, Parkitny L, Stanton TR, Moseley GL, et al. Psychological Distress Mediates the Relationship Between Pain and Disability in Hand or Wrist Fractures. J Pain 2015;16:836–43.

31. Kilbane BJ. Another angry adolescent: another boxer’s fracture? Pediatr Emerg Care 2014;30:558–60. 32. Kural C, Alkaş L, Tüzün S, Cetinus E, Ugras AA, Alkaş M. Anger scale and anger types of patients with fifth metacarpal neck fracture. Acta Orthop Traumatol Turc 2011;45:312–5. 33. Beerthuizen A, Stronks DL, Huygen FJ, Passchier J, Klein J, Spijker AV. The association between psychological factors and the development of complex regional pain syndrome type 1 (CRPS1)-a prospective multicenter study. Eur J Pain 2011;15:971–5. 34. Vranceanu AM, Bachoura A, Weening A, Vrahas M, Smith RM, Ring D. Psychological factors predict disability and pain intensity after skeletal trauma. J Bone Joint Surg Am 2014;96:e20.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Psikolojik faktörlerin beşinci metakarpal boyun kırıklarının klinik sonuçları üzerine etkileri ve yaralanma etiyolojisi ile ilişkisi Dr. Levent Adıyeke,1 Dr. Suavi Aydoğmuş,2 Dr. Mustafa Sabuncuoğlu,3 Dr. Emre Bilgin,4 Dr. Tahir Mutlu Duymuş5 Haydarpaşa Numune Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, İstanbul Maltepe Devlet Hastanesi, Ortopedi Kliniği, İstanbul 3 Ümraniye Eğitim ve Araştırma Hastanesi, Psikiyatri Kliniği, İstanbul 4 İzmir Tepecik Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, İzmir 5 Özel Saygı Hastanesi, Ortopedi Kliniği, İstanbul 1 2

AMAÇ: Acil kliniğe başvuran hastalar arasında 5. metakarp boyun kırığına bağlı yaralanmalar yaygındır. Travma mekanizması çeşitli tiplerde olabildiği gibi bazı durumlarda istemli yaralanamalar görülebilmektedir. Beşinci metakarpal boyun kırık yaralanmaları etiyolojiye bağlı olarak tedavi ve rehabilitasyon aşamalarında psikolojik faktörlerin önemli rolü olabilmektedir. Bu aşamada istemli veya istemsiz olarak meydana gelen yaralanmalarının sonuçlarının karşılaştırıldığı bir araştırma yapılmamıştır. Bu çalışmada, yaralanma mekanizmaları arasındaki sosyoekonomik düzey, eğitim seviyesi ve klinik sonuçlar arasındaki ilişkiyi incelemeyi amaçladık. GEREÇ VE YÖNTEM: Bu çalışma metakarp boyun kırıklı 59 hastayı kapsamaktadır. Hastalar iki ayrı grup olarak değerlendirildi. Grup 1 istemli yaralanmalı hastalar ve Grup 2 istemsiz yaralanmalı hastalar ile oluşturuldu. Her iki grup öfke analizi, dürtüsel düzey ve anksiyete düzeylerinin somatik bulgular VAS ve Q-DASH skorları ile olan ilişkisi açısından değerlendirildi. Ayrıca öfke, dürtüsellik ve anksiyete düzeylerinin sosyoekonomik ve eğitim seviyesi ile olan ilişkisi değerlendirildi. BULGULAR: Grup 2 hastalarda öfke ve dürtüsellik değerleri Grup 1’e göre daha düşük olduğu ve Grup 2’deki bu düşük değerlerin VAS ve Q-DASH skorındaki düşüşle parelel olduğu görüldü. Grup 1 hastalarda Barrat dürtüsellik skor 61.5 (42–78), anksiyete skor 64 (55–77), öfke skoru 20 (16–30) ve Grup 2’de barrat dürtüsellik skor 61 (55–69), anksiyete skor 66 (58–72), öfke skoru 19 (14–26) ortalama değer olarak bulundu. Eğitim düzeyi düşük olan hastalarda dürtüsellik skor değerleri ve öfke skor değerleri Grup 2’de düşük bulunmuştur. Düşük gelire sahip hasta sayısı her iki grupta yüksek olarak bulunmuş ve bu hastalarda dürtüsellik skor değeri, öfke skor değeri Grup 1’de yüksek, anksiyete skor değeri Grup 2’de yüksek olarak bulunmuştur. TARTIŞMA: Sosyodemografik faktörlerin ve etiyolojinin istemli yaralanma oluşmasında psikolojik faktörler açısından etkinliği saptanamamış, ancak istemli beşinci metakarp boyun kırıkların klinik olarak el fonksiyonları üzerindeki etkileri ve tedavi sonrası ağrı seviyesinde etkili rol oynadığı görülmüştür. Anahtar sözcükler: Acil; ağrı; beşinci metakarp; etiyoloji; istemli yaralanma. Ulus Travma Acil Cerrahi Derg 2019;25(4):403-409

doi: 10.5505/tjtes.2018.93928

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ORIG I N A L A R T IC L E

Examining implant superiority in the treatment of simple pertrochanteric fractures of the proximal femur in elderly patients Mehmet Ali Talmaç, M.D., Mehmet Akif Görgel, M.D., Raffi Armağan, M.D., Mehmet Mesut Sönmez, M.D., Hacı Mustafa Özdemir, M.D. Department of Orthopedics and Traumatology, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey

ABSTRACT BACKGROUND: The aim of this study was to compare the clinical and radiological results of the proximal femoral nail antirotation (PFNA) with those of the dynamic hip screw (DHS) and percutaneous compression plate (PCCP) in the treatment of simple pertrochanteric fractures. METHODS: A total of 203 patients were included in the study. PFNA fixations were performed in 73 patients (PFNA group), DHS in 68 patients (DHS group), and PCCP in 62 patients (PCCP group). The main outcome measurements were perioperative properties, the Harris hip score, changes in the neck–shaft angle, and loss of the abductor muscle strength. Data were compared between the groups. RESULTS: The mean estimated total blood loss and the number of patients receiving the blood transfusion rate in the PFNA group were statistically significantly lower. The mean operation and fluoroscopy times in the PCCP group were statistically significantly higher. The mean loss of the abductor muscle strength and changes in the neck–shaft angle in the PFNA group were statistically significantly higher. The mean Harris hip scores were similar. CONCLUSION: Our findings demonstrated that although PFNA was superior with regard to the perioperative data, DHS and PCCP were superior in maintaining the reduction and the abductor muscle strenght. All three implants were similar and had satisfactory functional outcomes. Keywords: Fixation devices; fracture fixation; hip fractures; osteosynthesis.

Fractures of the proximal femur trochanteric region are common and are associated with increased mortality and morbidity, especially in the elderly population.[1–3] According to the Orthopedic Trauma Association classification system, simple pertrochanteric fractures are classified as AO/OTA 31A1.[4] These fractures are characterized by intact lateral walls. Their incidence, generally occurring after a simple fall and being associated with bone fragility, increases with age.[5]

implant is still the subject of discussion. Proximal femoral nail antirotation (PFNA) allows weight bearing on the affected limb and early mobilization and provides angular and rotational stability.[6] Dynamic hip screw (DHS) is the most common implant used for the fixation of simple pertrochanteric fractures. [7] In the literature,[8] functional and radiographic outcomes were similar between the PFNA and DHS. The percutaneous compression plate (PCCP) is an extramedullary fixation device that retains the fracture hematoma, minimizes soft tissue damage, and avoids excessive periosteal stripping.[9]

The AO/OTA 31A1 fractures treating options include extramedullary and intramedullary fixation methods. The ideal

Although meta-analyses and reviews in the literature do exist,[6,10] a comparative clinical study examining the fixation of

INTRODUCTION

Cite this article as: Talmaç MA, Görgel MA, Armağan R, Sönmez MM, Özdemir HM. Examining implant superiority in the treatment of simple pertrochanteric fractures of the proximal femur in elderly patients. Ulus Travma Acil Cerrahi Derg 2019;25:410-416. Address for correspondence: Mehmet Ali Talmaç, M.D. Şişli Hamidiye Etfal Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, İstanbul, Turkey Tel: +90 212 - 373 50 00 E-mail: drtalmac2@gmail.com Ulus Travma Acil Cerrahi Derg 2019;25(4):410-416 DOI: 10.14744/tjtes.2019.21270 Submitted: 11.01.2019 Accepted: 30.04.2019 Online: 08.07.2019 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

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Talmaç et al. Examining implant superiority in the treatment of simple pertrochanteric fractures of the proximal femur in elderly patients

simple pertrochanteric fractures with PFNA, DHS, and PCCP is, to the best of our knowledge, yet to be published. We aimed to compare the clinical and radiological results of PFNA with those of DHS and PCCP for simple pertrochanteric fractures.

MATERIALS AND METHODS This is a retrospective clinical study conducted following the approval of the ethical committee of our hospital. We identified 246 patients aged 65–80 years diagnosed with a simple pertrochanteric fracture and who underwent fixation using PFNA (Tasarimmed, Istanbul, Turkey), DHS (Synthes Inc, West Chester, PA, USA), or PCCP (Orthofix SRL, Verona, Italy) between January 2011 and December 2016. Our exclusion criteria were as follows: age 65–80 years; AO/ OTA 31A1.1, 31A2, and 31A3 fractures; bilateral hip fracture; pathologic fractures; another fracture in the extremities or spine; open fractures; a history of lower-limb fracture or deformity; previous ipsilateral lower-limb surgery; contralateral hip fracture within the last year; cognitive impairment; and severe concomitant medical condition (Grades IV and V American Society of Anesthesiologists [ASA] score).[11] Additionally, 12 patients were lost to follow-up. A final total of 203 patients were included in the study. Seventy-three patients were treated with PFNA (Group PFNA), 68 patients with DHS (Group DHS), and 62 patients with PCCP (Group PCCP). Data for this study were collected from patient records, a digital data bank, which included information on patients who were operated, and outpatient clinic notes. First, we analyzed mortality, orthopedic complications, and reoperation rates between the groups. Sixty-three patients because of mortality and a total of 15 patients because of orthopedic complications or reoperation requirements were excluded from the second analysis. A total of 125 patients were analyzed with respect to the pre- and perioperative patient characteristics and postoperative data. Forty-five patients were in the PFNA, 42 in the DHS, and 38 in the PCCP group. Pre- and perioperative patient characteristics were collected following consent; these included age, gender, body mass index (BMI; kg/m²), the affected side, fracture etiology, AO/ OTA classification of fractures,[4] Charlson comorbidity index (CCI),[12] ASA grade of the operative risk,[11] preoperative hemoglobin (g/dL) and hematocrit (mm/h) values, an estimated total blood loss (ml), patients receiving blood transfusion, preoperative time (days), operation duration (minutes), fluoroscopy duration (seconds), quality of reduction, and the length of hospital stay (days). Postoperative data of the patients included the following: bone healing time (weeks), evaluated during the whole follow-up period, and clinical and radiological evaluation criteria evaluated only on the final follow-up. The latter included the Harris Ulus Travma Acil Cerrahi Derg, July 2019, Vol. 25, No. 4

hip score (HHS),[13] loss of abductor muscle strength (AMS) (%), and change in the neck-shaft angle (NSA) (degrees). All patients were classified using preoperative anteroposterior and lateral radiographic views as AO/OTA 31A1.2 or 31A1.3 according to the Orthopedic Trauma Association classification system (Fig. 1). The estimated total blood loss (ml) was calculated from the total volume of intraoperative aspiration fluids, drains, and blood on the gauze pad. The blood transfusion criterion was a hemoglobin level <9 g/dL. Anteroposterior and lateral radiographic views of the affected hip were evaluated 1–7 days after the operation and at each

Figure 1. Preoperative anteroposterior radiographic view of a patient with a 31A1.2 fracture according to the Orthopedic Trauma Association classification system.

(a)

(b)

(c)

Figure 2. Early postoperative anteroposterior radiographic views of patients who had (a) PFNA, (b) DHS, and (c) PCCP.

(a)

(b)

(c)

Figure 3. Final follow-up anteroposterior radiographic views of patients who had (a) PFNA, (b) DHS, and (c) PCCP.

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follow-up visit in all patients (Fig. 2). Patients in both groups were followed up in the 6th week, 3rd month, 6th month, 9th month, and 1st year postoperatively. We also classified the quality of reduction as follows: poor (>10 degrees of varus, valgus, anteversion, or retroversion), acceptable (5–10 degrees), or anatomic (≤5 degrees).[14] Evaluations of function and mobilization were assessed using HHS,[13] scaled from 1 to 100 points. Bilateral anteroposterior and lateral radiographs of the hip were conducted on the final follow-up (Fig. 3). The changes in NSA were calculated from differences observed between the affected and non-effected sides using anteroposterior radiographic views. Additionally, we measured the bilateral AMS of all patiens using a handheld dynamometer (Baseline Digital Smedley Spring Hand Dynamometer, Park City, UT, USA). The loss of AMS was calculated from differences observed between affected and non-effected sides. All variables were compared between the groups.

Surgical Procedure and Postoperative Management

possible. Implant components were applied according to techniques recommended by the manufacturer. A postoperative fracture reduction and implant positioning were assessed by fluoroscopy. A single dose of first-generation cephalosporin (sefazolin sodium) (1 g) prophylaxis was administered prior to surgery to all patients; four additional cephalosporin doses were administered postoperatively. In addition, low-molecular-weight heparin was administered from the hospitalization day 1 for 4 weeks after the operation as deep venous thrombosis prophylaxis. Active and passive exercises of the ankle and hip joints, as well as quadriceps strengthening, were initiated under the guidance of the surgeon. All patients were mobilized using a walking frame within 3 days. Three days after the procedure, the patients with PFNA started the partial weightbearing movement (i.e., 15% of thebody weight), gradually transitioning to full weight-bearing movement 6 to 8 weeks after the procedure, depending on the fracture healing. Patients with DHS and PCCP started the partial weight-bearing movement (again, 15% of body weight) after callus was identified using X-ray fluoroscopy (i.e., 3 weeks after the procedure), gradually transitioning to the full weight-bearing movement, depending on the fracture healing speed.

Patients were admitted to the Emergency Department of our hospital after sustaining injury and were transferred to our department following stabilization of their systemic condition. Surgical treatment was performed as soon as possible. All procedures were performed under spinal or general anesthesia.

Statistical Analysis

For fixation, patients were positioned supine on the radiolucent operation table, and closed reduction was performed with manual traction under C-arm fluoroscopic monitoring. Povidone–iodine or chlorhexidine was used for the sterile preparation of the injured limb prior to performing the procedure. A minimally invasive approach was used, whenever

The SPSS 20.0 for Windows 7 (IBM, Inc., Armonk, NY, USA) was used for statistical analysis. Descriptive statistics were given as the number and percentage for categorical variables and the mean and standard deviation for numerical variables. The numerical variables in the more than two groups were compared using the one-way analysis of variance when provided the normal distribution condition in the groups. The

Table 1. Comparison of the mortality, orthopedic complications, and reoperation rates Variable

PFNA group (n=73)

DHS group (n=68)

PCCP group (n=62)

p*

n %

n %

n %

Mortality in 1 year

16

21.9

12

17.6

13

21

0.806

Total mortality

23

31.5

22

32.4

18

29

0.914

Periprosthetic fracture

0

0.0

1

1.5

0

0

0.637

Limb length discrepancy (>25 mm)

0

0.0

6

8.8

4

6.5

0.021#

Malunion

4

5.5

2

2.9

1

1.6

0.566

Nonunion

2

2.7

1

1.5

1

1.6

1.000

Heterotopic ossification

2

2.7

3

4.4

2

3.2

0.895

Screw cut-out

5

6.8

5

7.4

2

3.2

0.563

Implant failure

0

0.0

1

1.5

0

0

0.637

Osteolysis with well-fixed implants

1

1.4

0

0

0

0

1.000

Wound infection

2

2.7

1

1.5

1

1.6

1.000

Reoperation

5

6.8

4

5.9

6

9.7

0.694

*Chi-squared analysis. #Subgroup analysis: PFNA vs. DHS, p=0.011; PFNA vs. PCCP, p=0.042; DHS vs. PCCP, p=0.747. PFNA: Proximal femoral nail antirotation; DHS: Dynamic hip screw; PCCP: Percutaneous compression plate.

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numerical variables in more than two groups were compared using the Kruskal–Wallis test when no normal distribution condition was provided. The subgroup analysis was performed using the Mann–Whitney U test in nonparametric test. The ratios in the groups were compared using the chisquared analysis. The subgroup analysis was interpreted using the Bonferroni correction in nonparametric and chi-square tests. For all tests, the statistical significance was defined as an alpha level of p<0.05.

RESULTS There were no statistically significant differences with respect to mortality, orthopedic complications, and reoperation rates, except for the limb length discrepancy (LLD) between the groups (Table 1). The LLD rate in the PFNA group was

statistically significantly lower than that of DHS (p=0.011) and PCCP (p=0.042) groups. In the second analysis, the mean age of the 125 patients was 72±5.3 years, the mean BMI was 30.8±4.8, and 62 (49.6%) patients were male. The mean estimated total blood loss (ml) and the number of patients receiving the blood transfusion rates in the PFNA group were statistically significantly lower than in the DHS and PCCP groups. The mean procedure duration (minutes) and fluoroscopy (seconds) times in the PCCP group were statistically significantly higher than those in the PFNA and DHS groups. Pre- and perioperative characteristics of patients are presented in Tables 2 and 3. The mean HHS in the PCCP group was statistically significantly higher than the one in the DHS group. The mean AMS loss (%)

Table 2. Patient data Variable Age (years), mean±SD Sex (male/female), n Body mass index (kg/m²), mean±SD

PFNA group (n=45)

DHS group (n=42)

PCCP group (n=38)

p*

73.9±4.6

70.6±5.4

71.3±5.5

0.010

20/25

25/17

17/21

0.288

30.2±4.2

29.6±4.8

32.7±4.9

0.008**

Side (right/left), n

23/22

16/26

23/15

0.130

Fracture etiology (SF/FFH/MVA), n

41/1/3

40/0/2

35/1/2

0.946

AO/OTA classification (31A1.2/31A1.3), n Charlson comorbidity index, mean±SD

15/30

12/30

22/16

0.016

3.27±1.30

2.81±1.49

3.03±1.26

0.348

ASA grade, n (%)

I

7 (15.6)

11 (26.2)

8 (21.1)

0.648

II

18 (40)

11 (26.2)

13 (34.2)

III

20 (44.4)

20 (47.6)

17 (44.7)

Preoperative hemoglobin (g/dL), mean±SD

11.6±2.1

10.6±2.0

12.6±1.9

<0.001

Preoperative hematocrit, mean±SD

34.8±6.3

32.0±6.0

37.8±5.9

0.001

167.3±27.6

344.0±61.7

353.9±55.9

<0.001

5 (11.1)

14 (33.3)

11 (28.9)

0.037

Estimated total blood loss (mL), mean±SD Patients receiving the blood transfusion, n (%) Preoperative time (days), mean±SD

3.6±1.3

4.0±1.6

3.9±1.7

0.455

Operation time (minutes), mean±SD

26.1±5.6

25.6±5.5

35.3±9.6

<0.001

Fluoroscopy time (seconds), mean±SD

57.8±16.7

55.8±15.0

67.6±19.3

0.012

Length of hospital stay (days), mean±SD

5.6±1.6

5.9±1.8

5.6±1.6

0.667

Quality of reduction, n (%)

0.405

Good

24 (53.3)

22 (52.4)

25 (65.8)

Acceptable

21 (46.7)

20 (47.6)

13 (34.2)

Bone healing time (weeks), mean±SD

15.4±2.3

14.7±2.9

15.5±3.0

0.459

Harris hip score, mean±SD

75.4±8.7

70.8±5.9

77.8±8.6

0.003

Poor

Loss of AMS (%), mean±SD

21.8±5.8

2.6±3.7

3.1±4.4

<0.001

Change in the neck–shaft angle (degrees), mean±SD

2.49±1.04

1.43±0.59

1,26±0.69

<0.001

Follow-up period (years), mean±SD

4.13±1.63

3.95±1.48

4.26±1.62

0.713

Kruskal–Wallis test; **One-way analysis of variance. SF: Simple falling; FFH: Falling from a high; MVA: Motor vehicle accident; ASA: American Society of Anesthesiologists; AMS: Abductor muscle strength; PFNA: Proximal femoral nail antirotation; DHS: Dynamic hip screw; PCCP: Percutaneous compression plate; SD: Standard deviation.

*

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Table 3. Subgroup analysis of variables with statistically significant difference

PFNA vs. DHS

PFNA vs. PCCP

DHS vs. PCCP

p* p* p*

Age (years)

0.004 0.037 0.415

Body mass index

0.811

AO/OTA classification**

0.631 0.025 0.008

0.041

0.009

Preoperative hemoglobin (g/dL)

0.030

0.040

<0.001

Preoperative hematocrit

0.055

0.037

<0.001

Estimated total blood loss (ml)

<0.001

<0.001

0.585

Patients receiving the blood transfusion* 0.012 0.040 0.673 Operation time (minutes)

0.713

<0.001

<0.001

Fluoroscopy time (seconds)

0.598

0.022

0.004

Harris hip score

0.059

0.122

0.001

Loss of abductor muscle strength (%)

<0.001

<0.001

0.605

Change of neck-shaft angle (degrees)

<0.001

<0.001

0.299

*Mannâ&#x20AC;&#x201C;Whitney U test; **Chi-squared analysis. PFNA: Proximal femoral nail antirotation; DHS: Dynamic hip screw; PCCP: Percutaneous compression plate.

and NSA change (degrees) in the PFNA group were statistically significantly higher than those of DHS and PCCP groups. Postoperative data of patients are presented in Tables 2 and 3.

DISCUSSION Hip fractures which frequency increases with an advanced age have become a public health issue. Adult hip fractures should be treated surgically to prevent morbidity and mortality, improve patient mobilization, decrease the of length rehabilitation, improve the quality of life, and reduce costs and complications. Although numerous investigators have recommended treating the AO/OTA 31A1.2 and 31A1.3 fractures with an intramedullary nail, DHS, or PCCP,[15,16] to the best of our knowledge, no clinical studies have compared these three implants for these stable fractures. We therefore evaluated the pre-, peri-, and postoperative properties of patients who underwent PFNA or DHS or PCCP. Especially, we aimed to compare these implants with respect to the loss of AMS. We found that the mortality for the 1-year rates was 21.9%, 17.6%, and 21% in the PFNA, DHS, and PCCP groups, respectively. Total mortality rates were 31.5%, 32.4%, and 29%, respectively. In the literature, the mortality rate remains between 20% and 30% in the year following a hip fracture.[17,18] We detected that a total of 4 patients had wound infection, 12 patients had the screw cut-out, 7 patients had heterotopic ossification, 11 patients had malunion or nonunion, 1 had a periprosthetic fracture, 1 had implant failure, and 1 had osteolysis with well-fixed implants in the follow-up process. There was no statistically significant difference between the 414

groups in terms of these complications. In addition, the reoperation rates of the groups were similar. Orthopedic complications and reoperation rates remain between 5% and 30% in the literature.[19,20] The present study demonstrated that the mortality, orthopedic complications, and reoperation rates in groups were similar and consistent with the literature. The LLD usually occurs depending on the femoral neck subsidence after the fixation of proximal femoral fractures, and it adversely affects functional results. Therefore, we only evaluated patients with LLD in the first analysis and did not include patients with LLD in the second analysis, as well as patients with other complications. Zeng et al.[19] reported that DHSs had high LLD rates. Also, our study demonstrated that LLD rates in DHS and PCCP groups were statistically significantly higher than the PFNA group. Although mortality, other complications, and reoperation rates are similar, a low LLD ratio suggests that PFNA is biomechanically superior. In the present study, no patients had a poor reduction quality, and the number of anatomical reductions was similar in groups. Yu et al.[21] reported that all of their patients had an acceptable or higher quality of reduction with PFNA or DHS. Also, Cheng et al.[22] reported that no patients had a poor reduction quality with DHS or PCCP. In accordance with the literature,[23] we found that the mean estimated total blood loss and blood transfusion ratio were significantly lower in the PFNA group than in the DHS and PCCP groups. Contrary to the literature,[6] we found that the mean operation and fluoroscopy times were significantly higher in the PCCP group than in the PFNA and DHS groups. Additionally, there was no statistically significant difference Ulus Travma Acil Cerrahi Derg, July 2019, Vol. 25, No. 4


Talmaç et al. Examining implant superiority in the treatment of simple pertrochanteric fractures of the proximal femur in elderly patients

between the groups with respect to the duration of hospitalization. This study demonstrated that PCCP was inferior in most of the perioperative properties. Previous studies reported that patients who had 31A1 fractures may have rather different functional outcomes following fixation with various implants.[19–23] The present study demonstrated that the functional outcomes in the groups were similar and satisfactory, according to the HHS. Previous reports have stated that the union time for these fractures with various implants was 12–18 weeks.[21,24] The average bone healing time in the present study was in accordance with the literature, and there was no statistically significant difference between the groups. It is stated in the literature that maintaining reduction is more difficult with PFNA.[6] Also, we found that PFNA was inferior with respect to the mean NSA changes. In a cadaveric study, the gluteus medius superomedial footprint area was 501.5 mm² on average.[25] The proximal diameter of the PFNA is 16 mm, and the proximal end area is approximately 201 mm². Therefore, abductor muscles can be damaged during the intramedullary nail insertion through the tip of the greater trochanter. However, the risk of the abductor muscle damage is lower in extramedullary devices such as DHS and PCCP. Stasi et al.[26] indicate that the abductor muscle strength was the main predictor of the functionality of hip fracture patients. In general, previous studies have only assessed the HHS and change in NSA during the followup of hip fractures.[27,28] In the literature, to the best of our knowledge, there are no studies comparing intramedullary and extramedullary devices in terms of the AMS loss. One of the advantages of our study was the measured AMS loss on the final follow-up. In the present study, in addition to HHS and changes in NSA, we evaluated the AMS loss. We found that the mean AMS loss was significantly higher in the PFNA group than in the DHS and PCCP groups. Our results suggest that intramedullary nailing significantly damages the abductor muscles during the reaming of the tip of a greater trochanter. Based on our evaluation, although the mortality, reoperation, and other complications rates were similar, PFNA was biomechanically superior to extramedullary devices. PFNA is superior also with regard to most perioperative properties. However, we believe that DHS and PCCP are superior in terms of the NSA change and absent AMS loss. Despite our informative findings, this study has some limitations, including its retrospective design, a relatively small sample size, as well as the lack of a subgroup analysis of patients according to the fracture pattern, and no post-hoc power analysis. In addition, approximately two-fifths of the patients could not be evaluated on the final follow-up due to mortality, orthopedic complications, or reoperation during the follow-up. Furthermore, if possible, a prospective randomized controlled trial with a larger sample size should be conducted to enhance the statistical power. Ulus Travma Acil Cerrahi Derg, July 2019, Vol. 25, No. 4

Conclusion To summarize, although PFNA was superior according to the perioperative data and in terms of not causing LLD, DHS and PCCP were superior with regard to maintaining reduction and not causing the AMS loss. All three implants were similar and satisfactory with regard to functional outcomes. Our findings demonstrated that DHS or PCCP can be considered a good primary option to prevent the loss of AMS in elderly patients. Conflict of interest: None declared.

REFERENCES 1. Cornwall R, Gilbert MS, Koval KJ, Strauss E, Siu AL. Functional outcomes and mortality vary among different types of hip fractures: a function of patient characteristics. Clin Orthop Relat Res 2004;425:64−71. 2. Çelik H, Kara A, Sağlam Y, Türkmen İ, Aykut S, Erdil M. Can double fluoroscopy in the oblique position reduce surgical time and radiation exposure during intertrochanteric femur fracture nailing? Ulus Travma Acil Cerrahi Derg 2018;24:581−6. 3. Kaynak G, Ünlü MC, Güven MF, Erdal OA, Tok O, Botanlıoğlu H, et al. Intramedullary nail with integrated cephalocervical screws in the intertrochanteric fractures treatment: Position of screws in fracture stability. Ulus Travma Acil Cerrahi Derg 2018;24:268−73. 4. Marsh JL, Slongo TF, Agel J, Broderick JS, Creevey W, DeCoster TA, et al. Fracture and dislocation classification compendium - 2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma 2007;211−133. 5. Gullberg B, Johnell O, Kanis JA. World-wide projections for hip fracture. Osteoporos Int 1997;7:407−13. 6. Arirachakaran A, Amphansap T, Thanindratarn P, Piyapittayanun P, Srisawat P, Kongtharvonskul J. Comparative outcome of PFNA, Gamma nails, PCCP, Medoff plate, LISS and dynamic hip screws for fixation in elderly trochanteric fractures: a systematic review and network metaanalysis of randomized controlled trials. Eur J Orthop Surg Traumatol 2017;27:937−52. 7. Janzing HM, Houben BJ, Brandt SE, Chhoeurn V, Lefever S, Broos P, et al. The Gotfried PerCutaneous Compression Plate versus the Dynamic Hip Screw in the treatment of pertrochanteric hip fractures: minimal invasive treatment reduces operative time and postoperative pain. J Trauma 2002;52:293−8. 8. Aros B, Tosteson AN, Gottlieb DJ, Koval KJ. Is a sliding hip screw or im nail the preferred implant for intertrochanteric fracture fixation? Clin Orthop Relat Res 2008;466:2827−32. 9. Giancola R, Antonini G, Delle Rose G, Crippa C. Percutaneous compression plating versus gamma nail for the treatment of pertrochanteric hip fractures. Strategies Trauma Limb Reconstr 2008;3:9−14. 10. Parker MJ, Handoll HH. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults. Cochrane Database Syst Rev 2008;3:CD000093. 11. Shen J, Hu C, Yu S, Huang K, Xie Z. A meta-analysis of percutenous compression plate versus intramedullary nail for treatment of intertrochanteric HIP fractures. Int J Surg 2016;29:151−8. 12. Huusko TM, Karppi P, Avikainen V, Kautiainen H, Sulkava R. Randomised, clinically controlled trial of intensive geriatric rehabilitation in patients with hip fracture: subgroup analysis of patients with dementia. BMJ 2000;321:1107−11.

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Talmaç et al. Examining implant superiority in the treatment of simple pertrochanteric fractures of the proximal femur in elderly patients 13. Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg Am 1969;51:737−55. 14. Schipper IB, Steyerberg EW, Castelein RM, van der Heijden FH, den Hoed PT, Kerver AJ, et al. Treatment of unstable trochanteric fractures. Randomised comparison of the gamma nail and the proximal femoral nail. J Bone Joint Surg Br 2004;86:86−94. 15. Jones HW, Johnston P, Parker M. Are short femoral nails superior to the sliding hip screw? A meta-analysis of 24 studies involving 3,279 fractures. Int Orthop 2006;30:69−78. 16. Antonini G, Giancola R, Berruti D, Blanchietti E, Pecchia P, Francione V, et al. Clinical and functional outcomes of the PCCP study: a multi-center prospective study in Italy. Strategies Trauma Limb Reconstr 2013;8:13−20. 17. Moyet J, Deschasse G, Marquant B, Mertl P, Bloch F, et al. Which is the optimal orthogeriatric care model to prevent mortality of elderly subjects post hip fractures? A systematic review and meta-analysis based on current clinical practice. Int Orthop 2019;43:1449−54. 18. Tang VL, Sudore R, Cenzer IS, Boscardin WJ, Smith A, Ritchie C, et al. Rates of Recovery to Pre-Fracture Function in Older Persons with Hip Fracture: an Observational Study. J Gen Intern Med 2017;32:153−8. 19. Zeng X, Zhang N, Zeng D, Zhang L, Xu P, Cao L, et al. Proximal femoral nail antirotation versus dynamic hip screw fixation for treatment of osteoporotic type 31-A1 intertrochanteric femoral fractures in elderly patients. J Int Med Res 2017;45:1109−23. 20. Zhang L, Shen J, Yu S, Huang Q, Xie Z. Percutaneous compression plate versus dynamic hip screw for treatment of intertrochanteric Hip fractures: a meta-analyse of five randomized controlled trials. ScientificWorldJournal 2014;2014:512512.

21. Yu W, Zhang X, Zhu X, Yu Z, Xu Y, Zha G, et al. Proximal femoral nails anti-rotation versus dynamic hip screws for treatment of stable intertrochanteric femur fractures: an outcome analyses with a minimum 4 years of follow-up. BMC Musculoskelet Disord 2016;17:222. 22. Cheng Q, Huang W, Gong X, Wang C, Liang X, Hu N. Minimally invasive percutaneous compression plating versus dynamic hip screw for intertrochanteric fractures: a randomized control trial. Chin J Traumatol 2014;17:249−55. 23. Hao Z, Wang X, Zhang X. Comparing surgical interventions for intertrochanteric hip fracture by blood loss and operation time: a network meta-analysis. J Orthop Surg Res 2018;13:157. 24. Bhandari M, Schemitsch E, Jönsson A, Zlowodzki M, Haidukewych GJ. Gamma nails revisited: gamma nails versus compression hip screws in the management of intertrochanteric fractures of the hip: a meta-analysis. J Orthop Trauma 2009;23:460−4. 25. Philippon MJ, Michalski MP, Campbell KJ, Goldsmith MT, Devitt BM, Wijdicks CA, et al. Surgically Relevant Bony and Soft Tissue Anatomy of the Proximal Femur. Orthop J Sports Med 2014;2:2325967114535188. 26. Stasi S, Papathanasiou G, Chronopoulos E, Galanos A, Papaioannou NA, Triantafyllopoulos IK. Association between abductor muscle strength and functional outcomes in hip-fractured patients: a cross-sectional study. J Musculoskelet Neuronal Interact 2018;18:530−42. 27. Min WK, Kim SY, Kim TK, Lee KB, Cho MR, Ha YC, et al. Proximal femoral nail for the treatment of reverse obliquity intertrochanteric fractures compared with gamma nail. J Trauma 2007;63:1054−60. 28. Okcu G, Ozkayin N, Okta C, Topcu I, Aktuglu K. Which implant is better for treating reverse obliquity fractures of the proximal femur: a standard or long nail? Clin Orthop Relat Res 2013;471:2768−75.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Yaşlı hastalarda proksimal femur basit pertrokanterik kırıkların tedavisinde hangi implant üstündür? Dr. Mehmet Ali Talmaç, Dr. Mehmet Akif Görgel, Dr. Raffi Armağan, Dr. Mehmet Mesut Sönmez, Dr. Hacı Mustafa Özdemir Şişli Hamidiye Etfal Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, İstanbul

AMAÇ: Bu çalışmanın amacı, basit pertrokanterik kırıklar için proksimal femur antirotasyon çivisinin (PFNA) klinik ve radyolojik sonuçlarını dinamik kalça çivisi (DHS) ve perkütan kompresyon plağı (PCCP) ile karşılaştırmaktır. GEREÇ VE YÖNTEM: Çalışmaya 203 hasta alındı. Hastaların 73’ünde PFNA (PFNA grubu), 68’inde DHS (DHS grubu) ve 62’sinde PCCP (PCCP grubu) ile fiksasyon yapıldı. Ana sonuç ölçümleri perioperatif özellikler, Harris kalça skoru, boyun-şaft açısının değişimi ve abdüktör kas kuvveti kaybı idi. Veriler gruplar arasında karşılaştırıldı. BULGULAR: Ortalama tahmini toplam kan kaybı ve kan transfüzyonu alan hasta oranı PFNA grubunda istatistiksel anlamlı olarak düşüktü. Ortalama operasyon ve floroskopi süreleri PCCP grubunda istatistiksel anlamlı olarak yüksekti. Ortalama boyun şaft açısındaki değişim ve abdüktör kas gücü kaybı PFNA grubunda istatistiksel anlamlı olarak yüksekti. Ortalama Harris kalça skorları benzerdi. TARTIŞMA: Bulgularımız, PFNA’nın perioperatif verilerde üstün olmasına rağmen DHS ve PCCP’nin redüksiyonun ve abdüktör kas gücünün sürdürülmesinde üstün olduğunu göstermiştir. Her üç implant da fonksiyonel sonuçlar açısından benzer ve tatmin edici idi. Anahtar sözcükler: Fiksasyon cihazları; kalça kırıkları; kırık fiksasyonu; osteosentez. Ulus Travma Acil Cerrahi Derg 2019;25(4):410-416

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doi: 10.14744/tjtes.2019.21270

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CAS E R EP O RT

Steel rod impalement injuries involving the spine: A case report and literature review Can Sarıca, M.D.,1 Şeyho Cem Yücetaş, M.D.,1 Necati Üçler, M.D.,1 Sadi Ballı, M.D.,2 Kasım Turgut, M.D.,3 Leyla Topçu Sarıca,4 M.D., Süleyman Kılınç, M.D.1 1

Department of Neurosurgery, Adıyaman University Faculty of Medicine, Adıyaman-Turkey

2

Department of General Surgery, Adıyaman University Faculty of Medicine, Adıyaman-Turkey

3

Department of Emergency Medicine, Adıyaman University Faculty of Medicine, Adıyaman-Turkey

4

Department of Anesthesiology and Reanimation, Adıyaman University Faculty of Medicine, Adıyaman-Turkey

ABSTRACT Steel rod impalements, mostly experienced by construction workers due to falls from heights, are known entities, but only some individuals unfortunately suffer spinal cord injury. The management of the spine involved injuries is challenging due to the lack of guidelines, various clinical presentations resulting from different trajectories, and high risk of infection. We report a case of steel rod impalement involving the spinal canal and review the literature to enhance the management strategies and to identify the risk factors for possible complications, particularly infection.A 37-year-old male construction worker presented to our emergency department due to falling onto a concrete reinforcing steel rod that penetrated through his perineum to the L4 vertebra. Examination revealed paralysis and sensory loss of the left foot. The rod was removed in the operating room (closed removal) under general anesthesia, followed by laparotomy. Rectal laceration was primarily repaired, and colostomy was performed. In a separate session, laminectomy was performed. At 3 months post-discharge, the patient was ambulatory with armrest based on the same motor examination performed on presentation This case is a good example of careful preoperative planning, multidisciplinary involvement, and appropriately sequenced interventions resulting in an acceptable outcome for an injury with high morbidity and mortality and demonstrates the feasibility and potential benefits of closed removal of the rod in an operating room just before laparotomy.The presence of an intestinal perforation increases the infection risk, but infections can still be prevented in this setting. Shorter time intervals between the incidence and surgery may reduce the infection rate. Keywords: Impalement; iron rod; penetrating spinal injury; rebar; steel rod.

INTRODUCTION Steel rod impalements, mostly experienced by construction workers due to falls from heights, are known entities, but only a few patients unfortunately suffer spinal cord injury (SCI). The management of these injuries is challenging due to the lack of guidelines, various clinical presentations resulting from different trajectories, and high risk of infection. They are mostly “once-in-a-lifetime” cases even for the reasonably experienced trauma surgeons. In addition to their rarity, not

knowing the management strategy beforehand is one of the major obstacles in achieving successful treatment outcomes in these emergent situations. The actual incidence of spinal trauma due to steel rod impalement has not been reported. “Other penetrating wounds: stabbing, impalement, etc.” accounts for only 0.3% of all SCIs, and steel rod impalements constitute only a part of these according to the National Spinal Cord Injury Database.[1]

Cite this article as: Sarıca C, Yücetaş ŞC, Üçler N, Ballı S, Turgut K, Topçu Sarıca L, et al. Steel rod impalement injuries involving the spine: A case report and literature review. Ulus Travma Acil Cerrahi Derg 2019;25:417-423. Address for correspondence: Can Sarıca, M.D. Adıyaman Üniversitesi Tıp Fakültesi, Beyin ve Sinir Cerrahisi Anabilim Dalı, Adıyaman, Turkey Tel: +90 416 - 223 16 90 E-mail: can.sarica@gmail.com Ulus Travma Acil Cerrahi Derg 2019;25(4):417-423 DOI: 10.5505/tjtes.2018.83727 Submitted: 01.08.2018 Accepted: 29.10.2018 Online: 08.07.2019 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

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SarÄąca et al. Steel rod impalement injuries involving the spine

Here, we present the case of a concrete reinforcing steel rod penetrating through the perineum into the L4 vertebral body, which was successfully managed using a multidisciplinary approach, with planned diagnostic workup and sequenced surgical procedures. We further discuss the management strategies with a review of previous case reports owing to the lack of guidelines for this rare condition.

CASE REPORT A 37-year-old male construction worker was admitted to our emergency department due to falling from the second floor onto a concrete reinforcing steel rod approximately 20 min before admission. On inspection, it was apparent that a steel rod had penetrated the skin through the perineum (Fig. 1). He was conscious with a respiratory rate of 17 breaths/min, blood pressure of 136/92 mmHg, and heart rate of 96 bpm. There was no active external bleeding. His medical history was not significant, and physical examination was normal, except for paralysis of the dorsal and plantar flexor muscles and numbness of the left foot. Multiplanar computed tomography (CT) of the lumbar spine revealed a foreign body penetrating through the perineum to the left posterosuperior margin of the L4 vertebral body (Fig. 2a-d). The patient was transferred to the operating room following the administration of tetanus for prophylaxis and empirical antibiotics (vancomycin 1 g intravenous (iv) by slow infusion over 1 h + meropenem 2 g iv). In addition to the neurosurgeons, general and cardiovascular surgeons were also included in the operating team.

tum. The rod damaged the sigmoid mesocolon and entered the spine through the anterior surface of the S1 vertebral body. Rectal laceration was primarily repaired, and colostomy was performed from the sigmoid colon to the abdominal wall. The patient was transferred to the intensive care unit post-surgery with a neurological examination finding similar to the preoperative state. New lumbar CT and lumbar magnetic resonance imaging (MRI) were ordered (Fig. 3a-d). The patient was again operated to remove the intracanalicular bony fragments 14 h after the incidence. He was placed in the prone position, and L5 laminectomy was performed. The bony fragments were ablated using an ultrasonic bone shaver (BoneScalpel; Misonix, NY, USA). On exploration, the anterior surface of the dura at the L4 and L5 vertebral levels was observed to have been lacerated longitudinally on the left side, and the cauda equina roots were also damaged at this level. A tissue sealant (Tisseel; Baxter, CA, USA) was used for repair, and an autogenic fat graft on the lesion was placed to prevent cerebrospinal fluid (CSF) leakage. The spine was stabilized by a transpedicular screw system (Fig. 4a-b). There was no significant motor function change after the surgery. On postoperative day 2, the urinary catheter was removed, and the patient did not report any urinary problems thereafter. His anal sphincter tonus was normal and could be constricted voluntarily. No sign of infection was seen on clinical and laboratory examinations; therefore, antibiotic treatment (vancomycin + meropenem) was terminated on day 14 after

(a)

(b)

(c)

(d)

The rod was loose and was gently pulled out externally before the surgery in the operating room under general anesthesia. Skin laceration was sutured, and the patient was placed in the supine position for laparotomy, which was performed via median umbilical incision by a general surgeon. There was no major vascular injury, but there was an approximately 1 cm laceration on the anterior surface of the rec-

Figure 1. The patient was impaled with a steel bar through his perineum.

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Figure 2. Sagittal (a), axial (b), and three-dimensional (c, d) views of the preoperative noncontrast CTs showing a foreign body (steel rod) penetrating through the perineum to the left posterosuperior margin of the L4 vertebral body.

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SarÄąca et al. Steel rod impalement injuries involving the spine

(a)

(b)

(c)

(d)

Figure 3. Sagittal (a) and axial (b) views of the post-laparotomy noncontrast CTs revealing bony fragments in the spinal canal. Sagittal (c) and axial (d) views of the post-laparotomy MRI revealing the association between cauda equina roots and bony fragments in the spinal canal.

(a)

(b)

(c)

(d)

Figure 4. Sagittal (a) and axial (b) views of the post-laminectomy noncontrast CTs revealing the removal of the bony fragments from the spinal canal. Sagittal (c) and axial (d) views of the post-laminectomy MRI revealing the decompression of the cauda equina roots.

the incidence. The patient was discharged with paralysis of the dorsal and plantar flexor muscles of the left foot. At 3 months following the injury, he was ambulatory using an armrest based on the same motor examination as that performed on presentation, with no bowel and urinary incontinence.

DISCUSSION Eight case reports involving nine patients with steel rod impalement injuries involving the spine were identified in an extensive review of the English literature on PubMed (Table 1). We concluded that steel rod impalement injuries sparing the spine are not extremely rare, with different entrance sites, such as the oral cavity,[2] orbita,[3] nose,[4] cranium,[5] neck,[6] thorax,[7] abdomen,[8] hand,[9] rectum,[10] buttock,[11] and groin. [12] Most victims of steel rod impalement injuries are construction workers, and we believe that occupational safety specialists have to focus on this type of injury to decrease the incidence of this mostly preventable condition. No specific management guideline is currently available owing to the rarity of this injury type. Thus, we aimed to discuss the current management strategies, particularly the controversial ones, in a step-by-step approach.

Management in the Emergency Department and Radiographic Studies A patient suspected with a steel rod impalement injury involving the spine must undergo complete trauma assessment upon arrival to rule out any serious-associated injuries.[13] Ulus Travma Acil Cerrahi Derg, July 2019, Vol. 25, No. 4

After ensuring a patent airway and hemodynamic stability, radiographic studies must be performed to determine the trajectory of the rod, which is most likely embedded in the bony spine, as seen in the reviewed case reports. In case of trauma parallel to the axis of the spine, the hardness of the bony spine largely reduces the penetrating energy of the rod, thereby blocking its passage. However, perpendicular or oblique injuries may cross the bony spine. Only 3 (30%) of the 10 patients in our review experienced such trauma, and the rodâ&#x20AC;&#x2122;s penetrating end exited the body only in one pediatric patient.[14] Multiplanar CT is ideal for assessing the trajectory of the rod, its associations with the viscera and major vessels, degree of spine involvement, bone fragments in the spinal canal, and hematomas, if any. CT angiography (CTA) may help to determine the vascular associations in case any vascular injury is suspected. Digital subtraction angiography can be an alternative to CTA. In our case, the conventional plain X-ray imaging was not used to save time, because it does not provide additional information to CT in this condition. However, it may be useful in cases in which there is difficulty in positioning the patient for CT due to the unavailability of rod scissors. Since rods are mostly ferromagnetic, MRI may cause heating or movement of the rod, which may exacerbate the neurological injury. 18-Fluorodeoxyglucose positron emission tomography/CT does not play any role in the initial management, but it can be useful in identifying spinal infection, which is likely after such injuries.[15] 419


420 L2-3

L5-S1

L1 pedicle

S1-5 Denis Zone III

Back - None

Perianal None

Below right scapula None

Perianal None

Fall from motorcycle (construction site)

Fall from height (construction site)

Fall from height

Fall from height

27 Male

66 Male

29 Male

15 Female

Horowitz et al. 1985[17]

Tokushige et al. 2000[16]

L5-S1 corpus

L4-S2

T12-S1

Right Buttock - None

Anus - None

Perineum None

Fall from height (construction site)

Fall from height (construction site)

Fall from height

30 Male

37 Male

32 Male

Wang et al. 2009[21]

Zhou et al. 2011[18]

Tan et al. 2012[19]

Schildhauer et al., 2005[22]

ISS

Site of entry - exit points of rods

Mechanism

Authors & Year Age (years), sex

5 hours

T9 paraplegia

Acute*

S1 paralysis

2 hours

Acute*

Intact

Paraparesis, urinary retention, decreased perianal sensation

3 hours

LLE paralysis

Acute*

Acute

L3 Paraparesis, sensory loss

Intact, lower back pain

*

TI

Presentation

Table 1. Steel rod Impalement injuries involving the spine in reported cases

Removal*, laparotomy, laminectomy [+] (simultaneous sessions)

Closed removal (on injury site), laparotomy laminectomy, fusion [+] (2 months btwn. sessions)

Open removal, laparotomy [+]

Removal*, laparotomy, laminectomy, reduction, S4 root reanastomosis, posterior fusion [-] (3 days btwn. sessions)

Closed removal (on injury site), laparotomy, laminectomy [+] (simultaneous sessions) –

Open removal, laminectomy, laparotomy [+] (simultaneous sessions)

Open removal, laparotomy, laminectomy [-] (simultaneous sessions)

Steroid Use

Treatment [+/- perforation]** (time gap)***

+*

Cefotaxime Amikacin

Oxacillin Gentamicin Clindamycin

Preoperatively

Metronidazole Cefmenoxime (initial) Amikacin (later)

Azlocillin (initial) Meropenem Norvancomycin (later)

Tobramycin disc

Cefotaxime Amikacin Cefotiam (initial) Imipenem Fosfomycin Arbekacin (after culture) –

Chloramphenicol Cefamandole

Postoperatively

Antibiotics

No improvement

Improved muscle strength, no urinary control

Full recovery after 3 months

Right heel numbness and a trace weakness of the right plantar flexion

Intact

Began to improve, died of sepsis (107th day)

Persistent L3 paraplegia

Outcome

+

+

+

+

Post. Inf. Comment

Epidural abscess on day 40

Rectal Infection (postlaparotomy day 5) Rectal CSF fistula (postlaminectomy day 12)

Wound infection (8th day) Presacral abscess

Paraspinal and psoas abscess (8th week) Drainage + antifungal therapy for a year

Comment

Sarıca et al. Steel rod impalement injuries involving the spine

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Sarıca et al. Steel rod impalement injuries involving the spine

Fall while sliding

Fall from height (construction site)

11 Male

37 Male

Ozaydın et al. 2018[14]

Our Case, 2018

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Infection is a major concern in this type of injury; it may even result in mortality as in the case presented by Tokushige et al.[16] Five (50%) patients in our review experienced infection after the initial surgery, and all the infected patients (100%) had intestinal (mostly rectal; 80%) perforations.[16–20] However, intestinal perforations do not always lead to infection, similar to our case or by Wang et al.[21] Three (30%) patients without any associated intestinal perforations did not experience any infection.[14,16,22] The time interval between the incidence and initial surgery was particularly reported in only four cases. Three of these patients with intervals of 2, 3, and 5 h developed an infection, but our patient who had an interval of <1 h did not.[16,18,19] Unfortunately, the use of statistical analyses was not suitable in this review to establish an association between the time interval and infection rates because of the small sample size. However, we hypothesized that shorter time intervals result in lower infection rates based on existing data. ISS: Involved spinal segment; TI: Time interval between the incident and first surgery; Post. Inf.: Postoperative infection; LLE: Left lower extremity. * Not specified in this case report. **± presence of rectal/intestinal perforation. ***Time gap between the abdominal and spinal operations.

– No improvement in neurological function Vancomycin Meropenem Vancomycin Meropenem <1 hour LLE paralysis L4-S1 Perineum None

Closed removal, laparotomy, laminectomy, fusion [+] (13 hours btwn. sessions)

– –* Ampicillin/ sulbactam Amikacin Ornidazole Acute* Intact S2-5 Denis Zone I Anus - Loin

Open removal, laparotomy [-]

Intact

Septic shock + Polymyxin B-immobilized fiber Imipenem/ Cilasttin Clindamycin – Acute LLE paralysis 1 : Gluteal region – None 2nd: Gluteal region - None 3rd: Perineum – None Fall from height (roof ) 58 Male Kanemura et al. 2013[20]

st

st

*

1 :2nd: L4 3rd: L3

st

nd

1 and 2 bar: closed removal 3rd bar: open removal, laparotomy [+]

Postoperatively Preoperatively

Motor and sensonsry disturbances below L3

Comment Post. Inf. Comment Outcome Antibiotics Steroid Use Treatment [+/- perforation]** (time gap)*** TI Presentation ISS Site of entry - exit points of rods Mechanism Authors & Year Age (years), sex

Table 1. Steel rod Impalement injuries involving the spine in reported cases (cont.)

Infection Prophylaxis, Embedded Foreign Body Removal, and Steroid Administration

Another factor that may affect the infection rate is the time interval between laparotomy and laminectomy. Three (75%) of the four patients who had simultaneous sessions of laparotomy and laminectomy developed postoperative infection, whereas two patients who had 13-hour and 3-day long intervals, respectively, between laparotomy and laminectomy did not. One patient developed an infection after laparotomy and was under antibiotic therapy for 2 months before laminectomy (Table 1). Tokushige et al.[16] advocated that if the rod first penetrates the intestine, and then the spine, it would result in an increased infection rate. Only two cases have been reported in the literature wherein the rod first penetrated the spine and then the intestine; one had a postoperative infection,[17] and the other showed full recovery without any infection.[16] Therefore, it was not possible to verify this hypothesis. In light of this evidence, the use of broad-spectrum antibiotics and tetanus prophylaxis on admission and in the postoperative period was recommended, similar to that reported in other studies,[23] particularly in the setting of intestinal perforation. The time interval between the incidence and surgery and laparotomy and laminectomy and order of spinal and intestinal penetration of the rod may affect the infection rates; however, further studies using larger case series are needed to verify these speculations. To the best of our knowledge, no patient in the literature received high-dose steroid therapy for this injury type. 421


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Our patient did not receive any steroids, because their effectiveness in SCI remains controversial.[24] However, their use is weakly suggested in SCI as an option by a recent guideline. [25] Furthermore, the effects of steroids on the infection rate are also controversial with studies denoting both increased[26] and decreased[27] rates. As stated in previous case reports, the embedded iron rod should not be removed at the incidence site or in the hospital by paramedics or emergency staff prior to the surgery, because it may create laceration in a major vessel wall, possibly causing major bleeding.[13,16,17] In addition, the removal of the rod at the incidence site may increase the infection rate. Two patients whose embedded rods were removed at the incidence site developed serious infections.[16,18] On the other hand, closed removal prior to the surgery in the operation room setting under the guidance of a general or cardiovascular surgeon may be beneficial, as seen in our case. One certain benefit of this approach is patient positioning. The patient can be easily placed in the supine position following closed removal of the rod, thereby making it easy to perform laparotomy. However, whether closed removal affects the infection rates remains unclear. The removal of the rod before the surgery helped us prepare the surgical site more effectively and interrupt the connection of the external environment with the body during the surgery. Touching the unsterile rod during open removal using sterile instruments may spread the microorganisms present on the rod to uncontaminated sites. However, it is mandatory to evaluate the trajectory of the rod and its association with the major vessels to avoid major bleeding by unplugging a lacerated vessel for a closed removal. Having a cardiovascular surgeon in the team during closed removal is logical, given the risk of an unexpected bleeding. Our case is a good example of closed removal of the rod; however, this condition may not be applicable in all cases, and careful preoperative evaluation of the patient is mandatory for decision-making.

Spinal Canal Decompression In our case, only a portion of the cauda equina roots at the affected level and side were damaged as a consequence of physical forces of the initial traumatic event. Unfortunately, the affected roots were completely damaged, possibly irreversibly, with the current management strategies. However, it is well-documented that undamaged or partially damaged roots may experience a cascade of secondary injury events (ischemia and expanded zone of neural tissue injury), which may result in newly developed neurological deficits.[28] The American Association of Neurological Surgeons and Congress of Neurological Surgeons guidelines recommend that surgical decompression within 24 h after SCI can be performed safely and is associated with an improved neurological outcome.[28] Therefore, laminectomy was performed, and the bony fragments were removed to minimize secondary damage and delayed complications. This delayed-onset injury may even occur years after the first impact, with the formation of reactive 422

bone and soft tissue, thus increasing further compression. [29] Surgical exploration has the advantage of identifying and repairing dural tears and may prevent the formation of CSF fistulas, pseudomeningoceles, and intradural infections.

Conclusion We believe that our case demonstrates a good example of careful preoperative planning, multidisciplinary approach, and appropriately sequenced interventions, resulting in an acceptable outcome in this injury type with high morbidity and mortality. It exceptionally demonstrated the feasibility and potential benefits of closed removal of the rod in the operating room just before laparotomy in selected patients. The presence of intestinal perforation increases the infection risk, but infections can still be prevented in this setting. Shorter time interval between the incidence and surgery may decrease the infection rates.

Acknowledgments This article is partly supported by the Turkish Neurosurgical Society.

Funding The authors have not declared a specific grant for this research from any funding agencies in the public, commercial, or not-for-profit sectors. Conflict of interest: None declared.

REFERENCES 1. Chen Y, Tang Y, Vogel LC, Devivo MJ. Causes of spinal cord injury. Top Spinal Cord Inj Rehabil 2013;19:1-8. 2. Lan ZG, Richard SA, Li J, Yang C. Nonprojectile penetrating iron rod from the oral cavity to the posterior cranial fossa: a case report and review of literature. Int Med Case Rep J 2018;11:41−5. 3. Agrawal A, Reddy VU, Kumar SS, Hegde KV, Rao GM. Transorbital Orbitocranial Penetrating Injury with an Iron Rod. Craniomaxillofac Trauma Reconstr 2016;9:145−8. 4. Yousefi J, Mobasher Jannat A, Ajudani R. Penetrating nose and maxillary sinus injury with a metal part of a military gun. J R Army Med Corps 2016;162:137−8. 5. Sonmez E, Borcek AO, Guven C, Hasturk AE. An iron rod stuck in the right motor cortex. Turk Neurosurg 2012;22:772−4. 6. Rautji R, Behera C, Dogra TD. An unusual fatal construction site injury in India: a case report. Med Sci Law 2009;49:222−3. 7. Liu YW, Tsai DL, Chou SH, Chen CW. Video-Assisted Thoracoscopic Surgery for Thoracic Impalement With an Iron Rod. Ann Thorac Surg 2017;104:1438−9. 8. Kaur K, Singhal SK, Bhardwaj M, Kumar P. Penetrating abdomino-thoracic injury with an iron rod: An anaesthetic challenge. Indian J Anaesth 2014;58:742−5. 9. El Alwany AM. Wrist watch causing impalement of the hand by a thick steel rod. J Hand Surg Eur Vol 2010;35:684. 10. Amarjothi JM, Williams R, Inpharasun SA. Impalement injury with transanal prolapse of bowel content due to intraperitoneal rectal tear. Indian J Surg 2015;77:72. 11. Lee SH, Park SY, Kim J, Huh YJ. Piercing injury of the pelvis with a steel

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Sarıca et al. Steel rod impalement injuries involving the spine bar. Orthopedics 2012;35:88−90. 12. Khandelwal A, Singh GP, Kharwar RK, Deganwa M. An iron rod restricting access to airway: an unusual presentation. Anaesthesiol Intensive Ther 2017;49:241−2. 13. Shahlaie K, Chang DJ, Anderson JT. Nonmissile penetrating spinal injury. Case report and review of the literature. J Neurosurg Spine 2006;4:400−8. 14. Ozaydin S, Gulleroglu A, Karaaslan B, Celebi S, Besik C, Toker MK, et al. Penetrating injury caused by a long iron bar: A case report. North Clin Istanb 2018;5:75−8. 15. Kim SJ, Kim IJ, Suh KT, Kim YK, Lee JS. Prediction of residual disease of spine infection using F-18 FDG PET/CT. Spine (Phila Pa 1976) 2009;34:2424−30. 16. Tokushige J, Inokuchi A, Kawaguchi H. Impalement injuries involving the spinal canal. J Orthop Sci 2000;5:614−7. 17. Horowitz MD, Dove DB, Eismont FJ, Green BA. Impalement injuries. J Trauma 1985;25:914−6. 18. Zhou Z, Song Y, Cai Q, Li T, Liu H. Penetrating injury of rectum and vertebral body by steel bar causing cauda equina syndrome. Spine (Phila Pa 1976) 2011;36:803−7. 19. Tan H, Guo QS, Zhang LY, Sun SJ, Yao YZ, Huang XY. Abscess formation in vertebral canal and presacral area following penetrating injury of rectum and sacral vertebra by a steel rod. Chin J Traumatol 2012;15:241−3. 20. Kanemura T, Hifumi T, Okada I, Kiriu N, Ogasawara T, Hasegawa E, et al. Management of a gluteal region impalement injury caused by three reinforced aluminum bars: a case report. J Med Case Rep 2013;7:295. 21. Wang LT, Wu CC, Hsiao CW, Feng CC, Chang CF, Jao SW. Steel bar

penetrating injury of rectum and vertebral body without severe morbidities: report of a case. Dis Colon Rectum 2009;52:346−8. 22. Schildhauer TA, Chapman JR, Mayo KA. Multisegmental open sacral fracture due to impalement: a case report. J Orthop Trauma 2005;19:134−9. 23. Heary RF, Vaccaro AR, Mesa JJ, Balderston RA. Thoracolumbar infections in penetrating injuries to the spine. Orthop Clin North Am 1996;27:69−81. 24. Bydon M, Lin J, Macki M, Gokaslan ZL, Bydon A. The current role of steroids in acute spinal cord injury. World Neurosurg 2014;82:848−54. 25. Fehlings MG, Wilson JR, Tetreault LA, Aarabi B, Anderson P, Arnold PM, et al. A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on the Use of Methylprednisolone Sodium Succinate. Global Spine J 2017;7:203S−11S. 26. Ito Y, Sugimoto Y, Tomioka M, Kai N, Tanaka M. Does high dose methylprednisolone sodium succinate really improve neurological status in patient with acute cervical cord injury?: a prospective study about neurological recovery and early complications. Spine (Phila Pa 1976) 2009;34:2121−4. 27. Cage JM, Knox JB, Wimberly RL, Shaha S, Jo C, Riccio AI. Complications Associated With High-dose Corticosteroid Administration in Children With Spinal Cord Injury. J Pediatr Orthop 2015;35:687−92. 28. Ahuja CS, Nori S, Tetreault L, Wilson J, Kwon B, Harrop J, et al. Traumatic Spinal Cord Injury-Repair and Regeneration. Neurosurgery 2017;80:S9−S22. 29. Conway JE, Crofford TW, Terry AF, Protzman RR. Cauda equina syndrome occurring nine years after a gunshot injury to the spine. A case report. J Bone Joint Surg Am 1993;75:760−3.

OLGU SUNUMU - ÖZET

Omurgaya saplanan çelik çubuk: Olgu sunumu ve literatür taraması Dr. Can Sarıca,1 Dr. Şeyho Cem Yücetaş,1 Dr. Necati Üçler,1 Dr. Sadi Ballı,2 Dr. Kasım Turgut,3 Dr. Leyla Topçu Sarıca,4 Dr. Süleyman Kılınç1 Adıyaman Üniversitesi Tıp Fakültesi, Beyin ve Sinir Cerrahisi Anabilim Dalı, Adıyaman Adıyaman Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Adıyaman 3 Adıyaman Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Adıyaman 4 Adıyaman Üniversitesi Tıp Fakültesi, Anestezioloji ve Reanimasyon Anabilim Dalı, Adıyaman 1 2

Yüksekten düşme sonrasında özellikle inşaat işçilerinin etkilendikleri çelik çubuk saplanması bilinen bir travma türüdür, fakat sadece çok az sayıda şanssız kişi bu tarz bir travma sonrasında spinal kord hasarı ile karşımıza gelmektedir. Yüksek enfeksiyon riski, farklı güzergahlara bağlı çok fazla varyasyon gösteren klinik tablolar ve ilgili herhangi bir mevcut kılavuzun bulunmaması bu tarz travmalarının başarılı yönetimini zorlaştırmaktadır. Bu yazıdaki amacımız, nadir görülen spinal kord hasarına neden olan çelik çubuk saplanması olan bir hasta sunmak, ilgili literatürleri tarayarak bu travmanın yönetimini geliştirmek ve enfeksiyon başta olmak üzere komplikasyonlara neden olan risk faktörlerini belirlemektir. Otuz yedi yaşında erkek inşaat işçisi çalışırken yüksekten düşme sonrası perinesinden girip L4 omurga gövdesine saplanan çelik çubuk nedeniyle başvurdu. Muayenesinde sol ayakta motor ve duyu kaybı mevcuttu. Çelik çubuk genel anestezi altında operasyon odasında çekildi ve sonrasında laparotomi ile rektal laserasyon primer onarılıp kolostomi açıldı. Farklı bir oturumda laminektomi yapıldı. Hastanın taburcu olduktan üç ay sonraki muayenesi gelişi ile aynıydı ve hasta koltuk değnekleri ile yürüyebiliyordu. Bu olgu, dikkatli bir ameliyat öncesi planlama, multidisipliner yaklaşım ve farklı sekanslı planlanan girişimler ile kabul edilebilir bir klinik sonuç elde edilmesi açısından örnek teşkil etmektedir. Laparatomi öncesi kapalı olarak çubuğun çıkartılabileceğinin uygunluğunu ve olası yararlarını ortaya koymaktadır. Bağırsak perforasyonu enfeksiyon riskini artırmaktadır fakat bu durumda bile enfeksiyon önlenebilir. Olay ve cerrahi arasındaki sürenin kısa olması enfeksiyon ihtimalini azaltabilir. Anahtar sözcükler: Çelik çubuk; enfeksiyon; penetran omurga yaralanması; saplanma. Ulus Travma Acil Cerrahi Derg 2019;25(4):417-423

doi: 10.5505/tjtes.2018.83727

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CA S E REP OR T

Spontaneous transvaginal small bowel evisceration following hysterectomy: a case report Fatih Yanar, M.D., Gizem Öner, M.D., Beyza Özçınar, M.D., Ali Fuat Kaan Gök, M.D., Cemalettin Ertekin, M.D. Department of General Surgery, İstanbul University Faculty of Medicine, İstanbul-Turkey

ABSTRACT Transvaginal small bowel evisceration is a rare, life-threatening condition, requiring urgent surgical intervention. In our case, ischemia developed in the intestinal segment with evisceration, with a laceration in the small intestine of the mesentery, and finally, a small bowel resection was required. An 89-year-old woman was brought to the hospital with a sudden onset of abdominal pain, which lasted for 4 hours. Upon the examination, it was found that approximately 50 cm of the small intestine was eviscerated from the vagina, with its mesentery. The intestines were edematous, and also there were signs of ischemia on the mesentery. The patient was urgently transferred to surgery. Functional end-to-end anastomosis was performed, following a 70 cm small bowel resection. The vaginal defect was repaired transvaginally. Transvaginal small bowel evisceration is rarely described in the literature. It is most commonly seen in postmenopausal, elderly women who underwent vaginal surgery before and who have enterocele. The treatment is an emergent surgical approach. Surgical treatment should be based on individual patient. Various surgical techniques have been described for the repair of transvaginal small bowel evisceration, such as vaginal, abdominal, laparoscopic, and combined approaches.Transvaginal small bowel evisceration should be considered in the differential diagnosis of patients with a sudden onset abdominal pain. Patients with an increased risk for transvaginal small bowel evisceration are postmenopausal women and patients who underwent vaginal surgery before. After the accurate diagnosis, patients should be operated as soon as possible, and necessary surgery should be done. Keywords: Post-hysterectomy; small bowel evisceration; vaginal surgery.

INTRODUCTION

CASE REPORT

Transvaginal small bowel evisceration is rare, but emergency surgery is required because of its potential morbidity and mortality. The risk factors include previous vaginal surgery, enterocele, and advanced age.[1,2] Although it usually presents with a less dramatic clinical condition, surgery is necessary to prevent complications, such as bowel ischemia, ileus, and peritonitis. In our case, the findings of ischemia developed in the intestinal segment with evisceration, so we wanted to describe the risk factors, clinical findings, and treatment modalities of this condition, which is rare in general surgery practice.

An 89-years-old female patient was admitted to the emergency surgery outpatient clinic with a sudden onset, increasing abdominal pain for 4 hours, and vaginal protrusion of bowels (Fig. 1a). Her detailed history showed that she did not have any trauma history or any complaints such as constipation or cough that would increase the intra-abdominal pressure. The patient had hypertension, so she was taking antihypertensive drugs regularly. Transabdominal hysterectomy was performed in a private center with a diagnosis of uterine prolapse 3 years before, and no postoperative complications developed.

Cite this article as: Yanar F, Öner G, Özçınar B, Gök AFK, Ertekin C. Spontaneous transvaginal small bowel evisceration following hysterectomy: a case report. Ulus Travma Acil Cerrahi Derg 2019;25:424-426. Address for correspondence: Gizem Öner, M.D. İstanbul Üniversitesi Tıp Fakültesi, Cerrahi Binası, 1. Kat, Genel Cerrahi Sekreterlik, 34091 İstanbul, Turkey Tel: +90 212 - 255 55 42 E-mail: onergizem@hotmail.com Ulus Travma Acil Cerrahi Derg 2019;25(4):424-426 DOI: 10.14744/tjtes.2019.57318 Submitted: 17.04.2018 Accepted: 22.05.2019 Online: 08.07.2019 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

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Yanar et al. Spontaneous transvaginal small bowel evisceration following hysterectomy

The patient was taken to the emergency surgery resuscitation room. She was stable, and her blood pressure was measured as 110/70 mmHg. The pulse rate was 85/min. Extensive tenderness was detected on abdominal examination. On the pelvic examination, it was observed that, approximately 50 cm of the small intestine accompanied by mesentery was discharged from the vagina, and the circulation of the intestines was deteriorated, while the intestine was hyperemic and edematous. It was detected in blood measurements as Hb/Htc 11.6 g/dL/36%; leukocytes, 9000/mm3; and lactate, 2.6. The intestines were covered with a hot and sterile saline-soaked compress, and the patient was taken to the operating room. The patient was also pre-op consulted by a gynecologist. Wide-spectrum antibiotic therapy was initiated with an appropriate fluid support before the operation. The patient underwent laparotomy with a median incision. In the exploration, it was seen that the loops of the small intestine were herniated from the vaginal stump. The intestinal loops were reduced to the abdomen. About 70 cm of the ileal loop starting 20 cm from the proximal end of the ileocecal valve was found to be edematous, hyperemic, and locally ischemic, and also hematomas and locally lacerated areas in the mesentery of intestinal loop were detected. The abdomen was clean, and no intestinal content or pus was detected in the abdomen. The resection of the intestinal loops was made because the vascularization had not improved despite of warming with a hot compress for 20 minutes. A 70 cm small intestine resection was performed 20 cm from the proximal end of the ileocecal valve. Proximal and distal ileal vascularization was normal. Side-by-side small intestine anastomosis was performed with staples using a 55 mm and a 75 mm linear stapler. Per-op consultation was made with the gynecologist. The vaginal stump was closed with the continuous suture and no. 1 vicryl (Fig. 1b). A 10 mm aspirate drain was placed to the Douglas pouch. The patient was taken to the service room after the operation. On the postoperative 3rd day, she started to drink liquids and was discharged on the 6th postoperative day. No complications were observed in the first-week and the first-month follow-up.

(a)

DISCUSSION The definition of spontaneous vaginal small bowel evisceration was first made by Hyernaux in 1864.[1] It is a rare, life-threatening condition that requires an urgent surgical intervention, and less than 100 cases have been described in the literature. [2,3] Unfortunately, there is not enough information about the recurrence rate of transvaginal small bowel evisceration in the literature. In a review of the study by Kowalski et al.,[3] 68% of the patients who developed vaginal evisceration were postmenopausal. Of these patients, 73% had previous vaginal surgery, and 63% had enterocele. A more frequent occurrence in postmenopausal women has been associated with decreased vaginal wall attenuation, atrophy, and decreased vascularity due to reduced estrogen.[4,5] Risk factors in premenopausal women are trauma caused by coitus, rape, and foreign bodies. The risk factors in postmenopausal women are an advanced age, previous vaginal surgical interventions, enterocele repair, and sudden increases in intra-abdominal pressure (cough, constipation).[6,7] Other previously reported risk factors include radiotherapy, abdominal or vaginal hysterectomy, perineal proctectomy, and it is rarely spontaneous.[5,7] Vaginal rupture in postmenopausal women is mostly from posterior fornix.[3,4] Transvaginal small bowel evisceration is a surgical emergency and is associated with a 6%â&#x20AC;&#x201C;10% mortality rate due to septicemia and thromboembolism. Complications related to vaginal small bowel herniation are bowel ischemia, intraabdominal sepsis, ileus, and deep vein thrombosis.[5,6,8] It is possible to reduce morbidity and mortality with an early diagnosis and appropriate emergency surgical intervention. Various surgical techniques have been described for the repair of transvaginal small bowel evisceration such as vaginal, abdominal, laparoscopic, and combined approaches. Surgical treatment should be decided based on the individual patient. If there is no evidence of ischemia in the eviscerated intestinal segment, and if it can be reduced to the peritoneal cavity without complications, it is possible to repair the vaginal

(b)

Figure 1. (a) On pelvic examination, small intestine with hyperemia and edema was discharge from vagina. (b) Vaginal stump was repaired transvaginally.

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defect with the vaginal approach.[2,6,8–10] Matthews et al.[11] concluded that transvaginal approach should be used only if the patient is medically stable and has no clinical evidence of peritonitis or bowel ischemia. If the intestinal segment cannot be reduced, and if strangulation findings are present, laparotomy should be performed, intestinal segments should be reduced into the abdomen, and intestinal segments should be evaluated carefully for ischemia. In our case, laparotomy was chosen because of the presence of ischemic findings in the intestinal segment, and there was laceration on mesentery. In addition, we chose laparotomy considering that the size of the vaginal defect may have caused air leakage. On the exploration, an area of ischemia was detected in the intestinal segment, a resection decision was made, and approximately 70 cm of the small intestine was resected. The anastomosis was deemed appropriate because of the good blood supply of the intestinal ends after the resection. Subsequently, the vaginal defect was repaired by the obstetrics and gynecology team. The vaginal stump was closed with continuous sutures and no. 1 vicryl, but also, there are different ways of closing the vaginal stump, such as continuous sutures or separated sutures. In addition, some surgeons propose to reinforce the vaginal stump with the graft or omental flap. [12,13] In this case, they were not used due to the patient’s age. Transvaginal small bowel evisceration is a rare condition that requires emergency surgery because it is life-threatening. Early diagnosis and an appropriate surgical intervention are required. As in our case, early surgical intervention with small bowel resection is appropriate for patients with ischemic findings in the intestine, and an early surgical intervention will contribute to the reduction in the mortality and morbidity, prevention of the short bowel syndrome development, and the protection of the small bowel.

Conflict of interest: None declared.

REFERENCES 1. Hyernaux M. Rupture traumatique du vagin; issue des intestines a l’extieur, application du grand forceps au Detroit superieur; gurison. Bull Mem Acad Med Belg 1864;2:957. 2. Ramirez PT, Klemer DP. Vaginal evisceration after hysterectomy: a literature review. Obstet Gynecol Surv 2002;57:462–7. 3. Kowalski LD, Seski JC, Timmins PF, Kanbour AI, Kunschner AJ, Kanbour-Shakir A. Vaginal evisceration: presentation and management in postmenopausal women. J Am Coll Surg 1996;183:225–9. 4. O’Brien LM, Bellin LS, Isenberg GA, Goldstein SD. Spontaneous transvaginal small-bowel evisceration after perineal proctectomy: report of a case and review of the literature. Dis Colon Rectum 2002;45:698–9. 5. Dharmalingam M, Greenhalf JO, Smith KM. Vaginal evisceration following total abdominal hysterectomy. J Obstet Gynaecol 2004;24:194–5. 6. Partsinevelos GA, Rodolakis A, Athanasiou S, Antsaklis A. Vaginal evisceration after hysterectomy: a rare condition a gynecologist should be familiar with. Arch Gynecol Obstet 2009;279:267–70. 7. Thomson AJ, Elbiss HE. Re: Vaginal evisceration following total laparoscopic hysterectomy: case report and review of the literature. Aust N Z J Obstet Gynaecol 2008;48:447–8. 8. Ho PW, Lee CW. Transvaginal small bowel evisceration and strangulation. ANZ J Surg 2008;78:726–7. 9. Rajesh S, Kalu E, Bong J, Wales N. Evisceration 5 years post abdominal hysterectomy. J Obstet Gynaecol Res 2008;34:425–7. 10. Somkuti SG, Vieta PA, Daugherty JF, Hartley LW, Blackmon EB Jr. Transvaginal evisceration after hysterectomy in premenopausal women: a presentation of three cases. Am J Obstet Gynecol 1994;171:567–8. 11. Matthews CA, Kenton K. Treatment of vaginal cuff evisceration. Obstet Gynecol 2014;124:705–8. 12. Narducci F, Sonoda Y, Lambaudie E, Leblanc E, Querleu D. Vaginal evisceration after hysterectomy: the repair by a laparoscopic and vaginal approach with a omental flap. Gynecol Oncol 2003;89:549–51. 13. Ben Safta Y, Ghalleb M, Baccari A, Hamdi El Kebir G, Daldoul S, Sayari S, et al. Vaginal cuff dehiscence and evisceration 11 years after a radical hysterectomy: A case report. Int J Surg Case Rep 2017;41:234–7.

OLGU SUNUMU - ÖZET

Histerektomi sonrası geç dönem transvajinal ince bağırsak evisserasyonu: Olgu sunumu Dr. Fatih Yanar, Dr. Gizem Öner, Dr. Beyza Özçınar, Dr. Ali Fuat Kaan Gök, Dr. Cemalettin Ertekin İstanbul Üniversitesi İstanbul Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İstanbul

Transvajinal ince bağırsak evisserasyonu nadir görülmekle birlikte, tanı konulduğu anda acil cerrahi girişim gerektiren bir klinik tablodur. Olgumuzda da evissere olan bağırsak segmentinde iskemi bulguları gelişmiş, ince bağırsak mezosunda yırtık oluşmuş ve ince bağırsak rezeksiyonu yapılması gerekmiştir. Seksen dokuz yaşında kadın hasta dört saattir olan ani başlayan karın ağrısı, bağırsakların vajinadan çıkma şikayeti ile getirildi. Hastanın yapılan muayenesinde yaklaşık 50 cm’lik ince bağırsak ansının mezosu ile birlikte vajenden evissere olduğu görüldü. Bağırsak ansları ödemli olup, yer yer iskemi bulguları ve mezoda yırtılma mevcuttu. Hasta acil olarak ameliyata alındı. Yetmiş cm’lik ince bağırsak rezeksiyonunu takiben fonksiyonel uc-uca anastomoz yapıldı. Vajen defekti transvajinal olarak çift kat üzerinden tamir edildi. Transvajinal ince bağırsak evisserasyonu literatürde az rastlanan bir durumdur. En sık postmenapozal, yaşlı, daha önceden geçirilmiş vajinal ameliyatı olan, enteroseli olan kadınlarda görülmektedir. Tedavisi acil cerrahi girişimdir. Yapılacak cerrahi hastanın bulgularına göre transvajinal olarak vajen güdüğünün tamir edilmesinden, laparotomi yapılmasına hatta bağırsak rezeksiyonu yapılmasına kadar değişiklik gösterebilir. Postmenapozal, daha önceden geçirilmiş vajinal ameliyatı olan hastalar gibi risk taşıyan hastalar ani başlayan karın ağrısı ile başvurduklarında transvajinal ince bağırsak evisserasyonu da ayırıcı tanıda düşünülmelidir. Tanısı konulduktan sonra da hastalar en kısa sürede ameliyata alınıp gerekli cerrahi girişim yapılmalıdır. Anahtar sözcükler: İnce bağırsak evisserasyonu; post-histerektomi; vajinal cerrahi. Ulus Travma Acil Cerrahi Derg 2019;25(4):424-426

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